Pelagic Squid Jig Permit Applications

OMB Control No: 0648-0589
Expires: 10/31/2018

U.S. DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
NATIONAL MARINE FISHERIES SERVICE

Pacific Islands Regional Office - SFD Permits
1845 Wasp Blvd., Bldg 176
Honolulu, Hawaii 96818
(808) 725-5000 ∙ Fax: (808) 725-5215

WESTERN PACIFIC PELAGIC SQUID JIG PERMIT
Please Print Legibly. Items marked with * are required. Note required documents and instructions on page 2.
Non-refundable application processing fee of $48.00 required. Make check payable to Department of Commerce, NOAA.
*VESSEL NAME: _____________________________________________________________ *VESSEL OFFICIAL NO: _____________________
USCG or State registration number

*VESSEL LENGTH: ________________ (feet) Permit is required for vessels >= 50 ft LOA)

*RADIO CALL SIGN: _______________________

*PERMIT HOLDER: _____________________________________________________________________

__________________________

First, Middle, & Last Name or Business Name to be designated Permit Holder

*Taxpayer ID Number (EIN or SSN)

*DATE OF BIRTH (Individual) OR INCORPORATION (Business): _______________________________ (MM/DD/YYYY)
*CONTACT PERSON: ______________________________________________________________ TITLE: _____________________________
First, Middle, & Last Name, if not same as permit holder

Corporate officer, business owner, partner

*BUSINESS MAILING ADDRESS: ______________________________________________ ___________________
Street/PO Box

City

____
State

_____________
ZIP

*BUSINESS PHONE: (______) ___________________ CELL PHONE: (______) ___________________
EMAIL: __________________________________________________________
Under penalty of perjury, I hereby declare that I, the undersigned, am the applicant, or authorized to complete and certify this application on behalf of the
applicant, and the information contained herein is true, correct, and complete to the best of my knowledge.

*APPLICANT: ___________________________________ ________________________________________
Printed Name of Person Submitting Application

Signature

*DATE: ____________________
(MM/DD/YYYY)

*APPLICANT TITLE: ___ Vessel owner, ___ Permit holder, ___ Corporate officer or partner, ___ Designated agent**, or ___ Other_____________
(Check only one)
*Application is for ___ a new permit or ___ a renewal? If renewal, previous permit number? ________________________
It is prohibited to file false information on any application for a fishing permit (50 CFR 665.15(b)).

Rev. 12/4/17

(page 2)

OMB Control No: 0648-0589
Expires: 10/31/2018

INSTRUCTIONS FOR APPLICATION:
Please print all information legibly. Illegible writing may cause delays or errors in permit processing.
Vessel Name: Write the vessel name that is marked on the vessel and/or listed on the US Coast Guard (USCG) certificate of documentation or
state/territory vessel registration form. If vessel is undocumented and has no name, please write N/A or None.
Vessel Official No.: Write the vessel’s USCG documented number or state/territory undocumented vessel registration number.
Vessel Length: Write the length overall as documented by the USCG or state/territory registration.
Radio Call Sign: Write the call sign registered with the FCC if available.
Permit Holder: Write the name of the person or business to whom the permit will be issued.
Taxpayer ID Number: For individuals, this is your Social Security Number (SSN); for businesses, this is the Employer Identification Number (EIN).
Date of Birth or Incorporation: Write the date of birth for individuals, or date of incorporation for businesses.
Contact Person, Business Address, Business Phone and other contact information: Write the contact person name, contact person title,
permit holder’s mailing address, and permit holder’s telephone number. These will be the address and phone number of record. In addition, please
provide the cell phone number, fax number, and email.
Applicant and Date: The new or renewing permit holder (if individual) or an officer or member of the business or corporation submitting the
application must print their name and write their signature. Write the full date (MM/DD/YYYY) when the application is signed.
Applicant Title: Check the role of the applicant. If the applicant is not the permit holder or an authorized representative of the business permit
holder, then a written, signed, and dated letter of authorization from the permit holder naming the applicant as a designated agent is required.
New or Renewal?: Check one. If this is a renewal, write the previous permit number associated with this vessel and permit holder.
REQUIRED DOCUMENTS: You must submit the following with the application form:
1) A copy of the vessel's current U.S. Coast Guard Certificate of Documentation (documented vessel) or registration certificate from a state/territorial
agency (undocumented vessel) showing the current vessel owner,
2) Payment by check or money order for the non-refundable application processing fee, payable to Department of Commerce, NOAA, and
3) **A signed letter from the permit holder authorizing the applicant as the agent, if the applicant is acting as an agent for the permit holder.
An application that is lacking required information, vessel registration or documentation, or payment will be considered incomplete. An incomplete
application will be abandoned if it is not completed within 30 days after reception, and you must inform PIRO within 15 days of any change of
information on the application form (50 CFR 665.13). It is prohibited to file false information on any application for a fishing permit (50 CFR
665.15(b)).
Mail application and all required documents to the address at the top left of page 1, or drop them off at the NMFS Honolulu Service Center, Pier 38,
Honolulu, HI (M-F, 8 am to 4 pm). Contact NMFS at [email protected] to inquire about availability of an online permit application.

OMB Control No: 0648-0589
Expires: 10/31/2018

PRIVACY ACT STATEMENT
Authority: The collection of this information is authorized under the Magnuson-Stevens Fishery Conservation and Management Act, 16 U.S.C 1801
et seq., the Western and Central Pacific Fisheries Convention Implementation Act (WCPFCIA; 16 U.S.C. 6901 et seq), the Marine Mammal
Protection Act, and the Endangered Species Act. The authority for the mandatory collection of the Tax Identification Number (TIN) is 31 U.S.C. 7701.
Purpose: In order to manage U.S. fisheries, the NOAA National Marine Fisheries Service (NMFS) requires the use of permits or registrations by
participants in the United States. Information on NOAA Fisheries permit applicants and renewing holders includes vessel owner contact information,
date of birth, TIN and vessel descriptive information. Permit holder information may be used as sampling frames for surveys.
Routine Uses: The Department will use this information to determine permit eligibility and to identify fishery participants. Disclosure of this
information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared within NMFS offices, in order to coordinate monitoring
and management of sustainability of fisheries and protected resources, as well as with the applicable State or Regional Marine Fisheries
Commissions and International Organizations. Disclosure of this information is also subject to all of the published routine uses as identified in the
Privacy Act System of Records Notice COMMERCE/NOAA-19, Permits and Registrations for the United States Federally Regulated Fisheries.
Disclosure: Furnishing this information is voluntary; however, failure to provide complete and accurate information will prevent the determination of
eligibility for a permit.
PAPERWORK REDUCTION ACT INFORMATION
Public reporting burden for this collection is estimated as follows: 15 minutes for the WP pelagic squid jig permit application and 2 hours for all permit
denial appeals. Each burden includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of
information, including suggestions for reducing this burden, to NMFS Pacific Islands Regional Administrator, 1845 Wasp Blvd., Bldg. 176, Honolulu,
HI 96818.
This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal
regulations in the Pacific Islands Region. This will enable NMFS and the Western Pacific Fishery Management Council to (a) determine who would
be affected by changes in management; (b) inform license holders of changes in fishery regulations; and (c) determine whether the objectives of the
fishery program are being achieved by monitoring entry and exit patterns and other aspects of the fisheries. The information is used in analyzing and
evaluating the potential impacts of regulatory changes on persons in the regulated fisheries as well as in related fisheries. Responses to the
collection are required to obtain the benefit of a license for the fishery involved (ref. 50 CFR 665.13). Data provided concerning the vessel and/or
business of the respondents are handled as confidential under the Magnuson-Stevens Fishery Conservation and Management Act (Sec. 402(b)).
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply
with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently
valid OMB Control Number.