American Samoa Pelagic Longline Limited Access Program -

OMB NUMBER: 0648-0490
Expires: 1/31/2018

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

AMERICAN SAMOA LONGLINE LIMITED ACCESS PERMIT
Application Type:
Please print legibly. All fields required unless noted otherwise. Provide required documents as instructed. Non-Refundable Application Processing
Fee: $67.00, payable by check or money order to: Department of Commerce, NOAA. Fee charged for all permit transactions unless otherwise
noted below.
PERMIT CLASS: ___ A = vessel 40’ LOA or less

___ B = 40.1’ – 50’

___ C = 50.1’ – 70’

___ D = 70’ or larger

___ Permit Renewal
___ Additional Permit Issuance
___ Registration of new or replacement vessel to permit OR De-registration of vessel from permit. (No Fee)
___ Permit Transfer (The transferring permit holder completes this section and signs, and the person receiving the permit completes the sections below and signs
as the permit applicant.)

TO: ___ Family member

___ Community organization

___ Person with documented participation in the American Samoa longline
fishery (participation in vessel size Class A for Class A only)

NAME: ________________________________________________________ Relationship: ______________________________
Print first and last name, or name of community organization

If Family member is checked

Under penalty of perjury, I hereby declare that I, the undersigned, am the current permit holder or authorized to complete and certify this application on
behalf of the current permit holder, and the information contained herein is true, correct, and complete to the best of my knowledge.

PERMIT TRANSFEROR: ____________________________________________ ________________________________________________
(Original permit holder)

Print first, middle initial, and last name

Signature

PERMIT NUMBER BEING TRANSFERRED: ____________________________
VESSEL NAME: ________________________________________

DATE: _____________________

VESSEL OFFICIAL NUMBER (USCG or AS): _______________________

VESSEL OWNER: __________________________________________________________ RADIO CALL SIGN: _________________________
PERMIT HOLDER: ________________________________________________________ TAXPAYER ID NUMBER: ________________________
First, Middle and Last Name, or Business Name

(SSN or EIN)

PERMIT HOLDER DATE OF BIRTH (individual) or INCORPORATION (business):
Complete the Supplementary Information Sheet on page 2 to list names and addresses of owners, partners, or officers.
BUSINESS MAIL ADDRESS: ______________________________________________ _________________________ _____ ____________
Number, street, apt. no.

BUSINESS PHONE: (______) _______________________

City/Village

State

ZIP

CELL: (_____) _________________________

(Please include the area code for each number)

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: ____________________________________________ ________________________________________ DATE: ______________
Print first, middle initial, and last name

Signature

Mail application to the address at the top left of this page. If your application is incomplete, you will be notified by PIRO. You have 30 days from the date of
notification to complete the application or your application will be considered abandoned (50 CFR 665.13). 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 an application for a fishing permit (50 CFR 665.15(b)).
Rev. 12/4/17

OMB NUMBER: 0648-0490
Expires: 1/31/2018

(page two)

American Samoa Pelagic Longline Access Entry Permit
SUPPLEMENTARY INFORMATION SHEET
Company/Corporation officers, owners, or partners:
NAME

MAILING ADDRESS

PERCENT OWNERSHIP

For office use only:
___ Previous ownership of longline vessel: Vessel Name: ___________________________________
USCG COD ______________ or AS Vsl Reg. _________________
___ Vessel used to legally harvest Pacific pelagic management unit species with longline gear in the EEZ around
American Samoa.
___ Fulfilled minimum harvest requirements for renewal
___ Current Protected Species Workshop certification (for renewal)
___ Certification of Limited Access Permit Transfer if applying for a transfer
___ Documented ownership or evidence of work (Participation) on an AS longline fishing vessel:

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Instructions for American Samoa Pelagic Longline Limited Access Permit Application
Application Type: Check which type of permit action you are applying for. Please submit a separate form for each permit. Only application for renewal,
an additional permit, or vessel registration/replacement is allowed. The non-refundable application processing fee is required for an application for
Renewal, Additional Permit, or Transfer.
For Permit Transfer: This section must be completed by the current permit holder(s) who is transferring the permit (transferor) to another person or
business (transferee). They must write their name, their signature, and date it. The permit number being transferred must be provided. NMFS may
request additional documentation to verify the transfer.
Vessel Information: Fill in the vessel name, official number (either USCG documented vessel number or state registered number for undocumented
vessels), vessel owner name, and radio call sign. If the vessel has no name, please draw a line in the vessel name field.
Permit Holder Information: Fill in the name of the person or business to whom the permit will be issued. This entity will be the permit holder for the
duration of the permit. Provide the taxpayer ID number: SSN for individual, or EIN (employer identification number) for a business. Fill in the date of birth
of the individual or the date of incorporation for the business. If there is more than one permit holder, provide the same information for each permit
holder. Any change in the name of the permit holder(s) will require a transfer.
Provide the mailing address, phone numbers, and email of the permit holder. This will be the address of record.
Permit Applicant: The person who submits the application must print his or her name and sign the form. Fill in the application date, and the applicant’s
title. If the applicant is not the permit holder or is not a member or officer of the business that holds the permit, the permit holder must provide a signed
letter of authorization that designates the applicant as the agent.
Supplementary Information Sheet: If the permit holder is a business or partnership, list all owners, partners, and officers of the company on this sheet.
Provide addresses and percent ownership for each.

OMB NUMBER: 0648-0490
Expires: 1/31/2018

Required Documents to provide with the application:
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 current vessel owner,
2) Payment for the non-refundable application processing fee, if required,
3) Documentation of harvest for Renewal,
4) Documentation of participation in the American Samoa longline fishery if applying for an Additional Permit or Permit Transfer,
5) For Transfers: A signed and notarized Certification of Limited Access Permit Transfer from the original permit holder confirming the transfer of an
American Samoa longline limited access permit, and
6) A signed letter from the permit holder authorizing the permit applicant as the agent, if the applicant is not the permit holder.
The vessel owner must have a current Protected Species Workshop (PSW) to renew the permit. If the vessel owner is a business, an officer or
authorized representative of the company must have a current PSW certificate. Contact [email protected] for workshop information.
If your application is incomplete, you will be notified by PIRO. You have 30 days from the date of notification to provide required documents, or your
application will be considered abandoned (50 CFR 665.13). 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 an application for a fishing permit (50 CFR 665.15(b)).
Submit Complete Application to: the address printed in the upper left corner of the first page, or contact the Permits Program at
[email protected] for information on online renewals of American Samoa longline permits, and other permits as available.
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: 45 minutes for American Samoa longline limited access initial permit issuance,
renewal, transfer or upgrade; 2 hours for permit appeal. Send comments regarding this burden estimate and 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 Western Pacific 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 regulatory changes on person 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 Numbers.