Form 3-200-15a Federal Fish and Wildlife Permit Application/Order Form

Form 3-200-15a (Rev. 08/2021)
U.S. Department of the Interior

PERMIT APPLICATION / ORDER FORM

First Order

Type of Activity: Re-Order Request
Inmate

Last Name

OMB Control No. 1018-0167
Expires 07/31/2023

Eagle Parts for Native American Religious Purposes (Bald
and Golden Eagle Protection Act, 50 CFR 22.22)
U.S. Fish and Wildlife Service
National Eagle and Wildlife Property Repository
6550 Gateway Road, Bldg. 128
Commerce City, CO 80022

BEFORE FILLING OUT THIS FORM, please access and print (if
necessary) the Frequently Asked Questions, and form
Instructions. Please retain the "NOTICES" page for your records.
First Name

Middle Name

Suffix (Sr.,
Jr., etc.)

Physical address (Street address; Apartment #, Suite #; no P.O. Boxes)
City

State

Zip code/Postal code

State

Zip code/Postal code

Mailing Address (if different than physical address)
City
Date of Birth
Home Phone Number

Permit Number: MB
(Not Applicable for 1st Order)
Cellular Phone Number

Work Phone Number

Email Address

Contact Person ( if you have no phone)

Phone Number of Contact Person

Full Name of Federally Recognized Tribe

Inmate Specific Data:
New Incarceration:

Yes

Enrollment Number*
Institution

Inmate Number

Chaplains Phone Number

Chaplain

No

Your order is not complete after filling out this page. For both orders and reorders, please make sure you answer
question 1 in Section E (located on the next page).
For first orders, please also fill out the "Certification of Enrollment in a U.S. Federally
Recognized Tribe" on page 3. (This page is not necessary for reorders unless you changed your Tribal enrollment.)
DESCRIPTION OF REQUESTED MATERIAL (Applicants are limited to one pending order at any given time.)
Species:

Age:

Bald

Adult

G
. olden

Immature

Either

Either

Section 1: If a whole eagle is not needed, please request only
the parts necessary for your religious purposes.
Note: Parts cannot be added to whole eagle orders.

Section 2: Loose Feather orders cannot be added
to whole eagle, pair of wings, or tail orders.
(Please select ONE)

Parts:

Items:
Whole Eagle
Or
Pair of Wings Only
Whole Tail Only

10 Quality
(8 wing, 2 tail)

Head
Pair of Feet
Trunk (body minus
the head, feet,
wings, and tail)

Or

Include Plumes

20 Miscellaneous
(Lower Quality, mixed)

Wings and Tail
Other: (specify)
I hereby certify that I am requesting eagle items for religious purposes and that the information submitted herein is complete and accurate to the best of my
knowledge. I understand that false statements made here may subject me to criminal penalties. There is no processing fee for this permit.
Date:

Signature:

Date of signature (mm/dd/yyyy)

====OFFICAL USE ONLY BELOW HERE====

Date Request Rcvd at NER: _____/_____/_____ initials: _____
Date Request Completed: _____/_____/_____ initials: _____
_____/_____/_____ initials: _____
Date Permit Issued:

Page 1 of 4

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Form 3-200-15a (Rev. 08/2021)
U.S. Department of the Interior

EAGLE PARTS FOR NATIVE AMERICAN RELIGIOUS PURPOSES
(Bald and Golden Eagle Protection Act, 50 CFR 22.22)
U.S. Fish and Wildlife Service
National Eagle and Wildlife Property Repository

OMB Control No. 1018-0167
Expires 07/31/2023

NOTE: A Federal Migratory Bird Eagle Parts and Feathers Request Form will authorize Native Americans to used eagle parts and feathers for
religious and cultural purposes, including healing, marriage, and naming ceremonies. Recognizing the significance of eagles to Native
Americans, the U.S. Fish and Wildlife Service (Service) established the National Eagle Repository (Repository) in the early 1970s to provide
Native Americans with the remains, parts and feathers of Golden and Bald eagles for religious purposes.
You should review Title 50 Parts 10, 13, 22.22 of the Code of Federal Regulations (CFR), Morton Policy, DOJ Eagle Feather Policy, Bald and
Golden Eagle Protection Act. You are responsible for reviewing and understanding these regulations before you request and accept a permit.
Please read “Frequently Asked Questions” and the pertinent regulations before you sign and submit your application.
Please provide the information requested below. If additional information needs to be provided that does not fit in the designated
spaces, add additional sheets to your application submission. You may use as many additional sheets as needed. Please number
pages accordingly using the page number box provided at the bottom of the sheet, and the corresponding question number.
You should be as thorough and specific as possible in your responses. Incomplete applications will be returned.

SECTION E.
Question
1)

Disqualification factor. Have you, the permittee, or your client (if a broker on behalf of your client):
• Been assessed a civil penalty or convicted of any criminal provision of any statue or regulation relating to the activity for
which the application is filed (50 CFR 13.21(b) (1);
• Been convicted, or entered a plea of guilty or nolo contendere, for a felony violation of the Lacey Act, the Migratory Bird
Treaty Act, or the Bald and Golden Eagle Protection Act. (50 CFR 13.21 (c)(1)):
• Had a permit revoked within the last five years for willfully violating any Federal or State statute or regulation, or any Indian
tribal law or regulation, or any law or regulation of any foreign country, which involves a violation of the conditions of the
permit or of the laws or regulations governing the permitted activity (50 CFR 13.28 (a)(1)) or failing to correct deficiencies
that were the cause of a permit suspension within 60 days (50 CFR 13.28 (a)(2)).

Answer "yes" if ANY of the events listed immediately above have occurred. Answer "no" if none of the events listed immediately
above have occurred.
Yes
No
If you answered “Yes”, provide: a) the individual’s name; b) date of conviction, civil penalty assessment or revocation;
c) charge(s), or reason(s) for revocation; d) location of the incident; e) court (if applicable, ticket, federal/state/tribal court etc.);
and f) legal action taken for each violation (i.e. fine, incarceration, probation…). Please be aware that a “Yes” response does not
automatically disqualify you from getting a permit.

2) I acknowledge that I have read the form Instructions and Frequently Asked Questions, and will forward all necessary
documentation to the National Eagle and Wildlife Property Repository, 6550 Gateway Road, Bldg. 128, Commerce City, CO
80022. I have also filled out all fields and questions in this application. Check this box to acknowledge:

Page 2 of 4

Form 3-200-15a (Rev. 08/2021)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires 07/31/2023

CERTIFICATION OF ENROLLMENT IN A U.S.
FEDERALLY RECOGNIZED TRIBE (Bald and Golden
Eagle Protection Act, 50 CFR 22.22)
(By Certifying Tribal Official)
U.S. Fish and Wildlife Service
National Eagle and Wildlife Property Repository

**Completed Certificate of Enrollment must be attached to process application if applying for First Order

EAGLE PERMIT APPLICANT: (Please print)
Name:
Address:
Telephone Number:
The U.S. Fish and Wildlife Service administers the Bald and Golden Eagle Protection Act, the Federal law
protecting eagles. This law provides for Native American use of eagle feathers for religious purposes. Eagles
and eagle feathers are accumulated by the Service’s National Eagle Repository and made available to Native
Americans.
Application for a permit to acquire eagle feathers requires certification that the requesting individual is an enrolled
member of an Indian tribe that is federally recognized under the Federally Recognized Tribal List Act of 1994, 25
U.S.C. 479a-1, 108 Stat. 4791 (1994). The certificate must be signed by the tribal official who is authorized to certify
that an individual is a duly enrolled member of that tribe, and must include the printed name and official title of that
certifying official. (50 CFR 22.22)

To be completed by Certifying Tribal Official Only

- - - - - - - - - - - - -

I certify that

is an enrolled member of the

(Printed Full Name of Applicant)

Tribe, Enrollment #
(Full Name of Federally Recognized Tribe)

I understand that making a false statement can make me subject to the criminal penalties of 18 U.S.C. 1001.

Printed name of certifying official:
Date:

Signature of Certifying Official:
Title:

Office phone no.

NOTE TO CERTIFYING OFFICIAL: Please expedite this completed Certification of Enrollment to
the applicant at the above address.
APPLICANT: Attach this completed certification to your Eagle Permit application and mail them
to the U.S. Fish and Wildlife Service, National Eagle and Wildlife Property Repository.

Page 3 of 4

Form 3-200-15a (Rev. 08/2021)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires 07/31/2023

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the following: the Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR
22; the Endangered Species Act (16 U.S.C. 1531-1544), 50 CFR 17; the Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21; the
Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15; the Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16; Convention
on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), 50 CFR 23; General Provisions, 50 CFR 10;
General Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 50 CFR 14.
Purpose: The collection of contact information is to verify the individual has an eligible permit to conduct activities that affect protected
species. The information the individual provides helps the FWS monitor and report on protected species and assess the impact of
permitted activities on the conservation and management of species and their habitats.
Routine Uses: The collected information may be used to verify an applicant’s eligibility for a permit to conduct activities with protected
wildlife; to provide the public and the permittees with permit related information; to monitor activities under a permit; to analyze data and
produce reports to monitor the use of protected wildlife; to assess the impact of permitted activities on the conservation and
management of protected species and their habitats; and to evaluate the effectiveness of the permit programs. More information about
routine uses can be found in the System of Records Notice, Permits System, FWS-21.
Disclosure: The information requested in this form is voluntary. However, submission of requested information is required to process
applications for permits authorized under the listed authorities. Failure to provide the requested information may be sufficient cause for
the U.S. Fish & Wildlife Service to deny the request.
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 to monitor take and disposition of migratory birds, under the applicable laws governing the requested activity, for which a
permit is requested, 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. 1018-0167.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 1 hour 30 minutes (reporting) and 30 minutes (recordkeeping)
Original submission - electronic: 2 hours 30 minutes (reporting) and 30 minutes (recordkeeping)
These estimates include 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.
FREEDOM OF INFORMATION ACT
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that
you identify any information that should be considered privileged and confidential business information to allow the Service to meet its
responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter or
page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

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