American Samoa Longline Limited Access Permit

OMB NUMBER:
0648-0490
Expires:
02/xx/20xx

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) 725-5190 – [email protected]

PACIFIC ISLANDS PERMIT APPLICATION

AMERICAN SAMOA LONGLINE LIMITED ACCESS PERMIT
Please print legibly. All items required. Note instructions and required documents on pages 2-3. Do not nail application or check. Send application via
secure email and pay non-refundable application processing fee of $69 online. No fee for vessel registration.
Application Type:
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 original 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 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: (______) _______________________
(Please include the area code for each number)

City/Village

State

ZIP

CELL: (_____) _________________________

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

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 following notification of the deficiency (50 CFR 665.13(c)(2)). You must inform
PIRO within 15 days of any change of information on the application form (50 CFR 665.13(d)). It is prohibited to file false information on any
application for a fishing permit (50 CFR 665.15(b)).

OMB NUMBER: 0648-0490
Expires: 02/xx/20xx

(page 2)

American Samoa Longline Limited Access 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
Application Type: Check which type of permit action you are applying for. Please submit a separate form for each permit. Only applications for renewal,
an additional permit, or vessel registration/replacement are allowed. The non-refundable application processing fee is required for renewal, additional
permit, or transfer. There is no fee for vessel registration/replacement to a permit.
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/territory registration 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 (social security number) for an 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 or email that designates the applicant as the agent for the permit holder.

(page 3)

OMB NUMBER: 0648-0490
Expires: 02/xx20xx

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.
Additional documents required for the complete 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) Documentation of harvest for permit renewal.
3) Documentation of participation in the American Samoa longline fishery for the applicant if applying for an additional permit or permit transfer.
4) If a renewal, a copy of the current Protected Species Workshop certificate of the vessel owner (see below).
4) If the applicant is a designated agent, attach a signed letter or email from the permit holder authorizing the permit applicant as the designated agent.
5) For fee payment, see instructions below.
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.
An application that is lacking required information and documents, vessel registration or documentation, or payment will be considered incomplete. An
incomplete application will be abandoned if it is not completed within 30 days following notification of the deficiency (50 CFR 665.13(c)(2)). You must
inform PIRO within 15 days of any change of information on the application form (50 CFR 665.13(d)). It is prohibited to file false information on any
application for a fishing permit (50 CFR 665.15(b)).
Submit Complete Application to NMFS PIRO via secure email and pay fee online per instructions at www.fisheries.noaa.gov/pacificislands/commercial-fishing/apply-pacific-islands-fishing-permit. PIRO will not accept hardcopy or mailed applications and checks.
Contact: Email [email protected] or call (808) 725-5190 if you have any questions.
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
(16 U.S.C. 1362 et seq.), and the Endangered Species Act (16 U.S.C. 1531 et seq.). 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 permit holders includes vessel owner contact
information, date of birth, Tax Identification Number, 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 within NMFS offices under the Privacy Act of 1974 (5 U.S.C. 552a) to coordinate monitoring and management 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
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply
with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid
OMB Control Number. The approved OMB Control Number for this information collection is 0648-0490. Without this approval, we could not conduct this
information collection. Public reporting for this information collection is estimated to be approximately 75 minutes per permit application for renewal,
transfer, or additional permit, 45 minutes per permit application for vessel registration, and 2 hours per permit denial appeal, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information
collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this
information collection, including suggestions for reducing this burden to the NMFS Pacific Islands Regional Office at [email protected]