Sample Tribal Permit Request Form

OMB Control No. 1018-0178

Expiration Date: ##/##/20##

Name of Village/Tribal Council:­­­­­­­­­­­­­­­­­­ __________________________________________

Mailing Address:________________________________________________________

Contact Phone #:____________________

Fax#:____________________

Email Address:_________________________________________________________

20## Spring/Summer Migratory Bird Harvest Invitation Request

Invitee Name:_________________________________________Date:_______________

Physical Address (as shown on ID): Hunting License #____________________

____________________________

____________________________

____________________________

Permanent Address (if different than ID):

____________________________

____________________________

____________________________

Are you an enrolled Tribal Member of the above Village? Yes______ No______

Do you have immediate family member(s) (spouse, children, grandparents, parents, grandchildren) that are current residents of the above named village?

Yes______ No______

If “Yes” please list those family members: _____________________________________

________________________________________________________________________To comply with Federal Regulations, Who will you be hunting for/with and why? (i.e. Teaching Youth Cultural Knowledge, Assisting Immediate Family members)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

INVITATION REQUEST: APPROVED______ DENIED______

Send one copy of the approved form to the harvester and one copy to:

Patty Brown-Schwalenberg, AMBCC Executive Director, 6200 Lake Oatis Parkway, Anchorage, AK 99507, or Fax: 907/562-4939 or email: [email protected]

NOTICES

PRIVACY ACT STATEMENT

Authority: The Migratory Bird Treaty Act (MBTA) of 1918 (16 U.S.C. 703-712) and the Fish and Wildlife Act of 1956 (16 U.S.C. 742d).

Purpose: The information collected will be used for the continuation of customary and traditional subsistence uses of migratory birds in Alaska and to prescribe regional information on when and where the harvesting of birds may occur.

Routine Uses: The information collected may be shared in accordance with the Privacy Act of 1974 and the routine uses listed in the System of Records Notices INTERIOR/FWS-21 Permits System (June 4, 2008) 73 FR 31877 and INTERIOR/FWS/-26, Migratory Bird Population and Harvest Systems - 64 FR 29055 (May 28, 1999) available at https://www.doi.gov/privacy/doi-notices.

Disclosure: Furnishing this information is voluntary; however, failure to provide the requested information may prevent the FWS from being able to determine the take’s legality or may limit FWS’ ability to monitor migratory bird harvests.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501 et seq), the U.S. Fish and Wildlife Service collects information necessary as a required condition of permits requested and authorized under the applicable laws governing the requested activity, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection of information and assigned Control No. 1018-0178.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information to average 30 minutes, including time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed form to this address.