Form 3-200-18 Federal Fish and Wildlife Permit Application Form - Take

Form 3-200-18 (Rev. 02/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires ##/##/####

Take of Golden Eagle Nests During Resource
Development or Recovery
(Bald & Golden Eagle Protection Act, 50 CFR 22.25)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

BEFORE FILLING OUT THIS FORM, please access
the Return Addresses (to obtain the email/postal
mail addresses where this form can be returned),
and read the form Frequently Asked Questions and
Instructions. Please retain the "NOTICES" page for
your records.

TYPE OF REQUEST
New Application
Renewal
Amendment

If requesting a renewal or amendment, provide Permit #

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details. See
instruction page(s) for information on how to make your application complete and help avoid unnecessary delays.

Complete if applying as an individual

A.

1.a. Last name

1.b. First name

2. Date of birth (mm/dd/yyyy)

B.

3.b. Alternate telephone number

3.a. Telephone number

1.c. Middle name or initial

1.d. Suffix

3.d. E-mail address

Complete if applying on behalf of a business, corporation, public agency, Tribe, or institution

1.a. Name of business, agency, Tribe, or institution

1.b. Doing business as (dba)

2. Tax identification no.

3. Description of business, agency, or institution

4.a. Principal officer Last name

4.b. Principal officer First name

5. Principal officer title

4.c. Principal officer Middle name/ initial 4.d. Suffix

6. Primary contact name

7.a. Business telephone number 7.b. Alternate telephone number

C.

7.c. Business fax number

7.d. Business e-mail address

All applicants complete address information

1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
1.b. City

1.c. State

1.d. Zip code/Postal code:

1.f. Country

1.e. County/Province

2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City

D.

2.c. State

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

All applicants MUST complete

1. A nonrefundable processing fee is required to process this permit, please attach check or money order payable to the U.S. FISH AND WILDLIFE
SERVICE. Federal, Tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the processing fee –
Please see link for processing fee cost and fee exempt status as outlined in 50 CFR 13.11(d). Click here for Processing Fees
2. Do you currently have or have you ever had any Federal Fish and Wildlife permits?
If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue:
Yes
No
3. Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and
the other applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit is complete and
accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001.
Signature of applicant/Principal Officer (No stamped signatures. Electronic signatures accepted.)

Date of signature (mm/dd/yyyy)

Please continue to next page

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Form 3-200-18 (Rev. 02/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires ##/##/####

Take of Golden Eagle Nests During Resource
Development or Recovery
(Bald & Golden Eagle Protection Act, 50 CFR 22.25)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

Note: A Federal permit to take golden eagle nests is available only to parties engaged in a resource development or recovery
operation and only when nests are inactive. An inactive nest is one that is not currently used by golden eagles as determined by the
absence of any adult, egg, or dependent young at the nest during the 10 days before the nest is taken. You must be at least 18
years old to apply for a migratory bird permit.
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.
As the permittee, you are legally responsible for ensuring that your subpermittees, staff, and volunteers adhere to the terms of your
permit.

SECTION E.
Questions
1) Attachments - In additions to this form, you should also attach the following to complete your application:
a) An appropriately scaled map or plat must be included which delineates the areas of the resource development or recovery
operation and identifies the exact location of each golden eagle nest you propose to take in decimal degrees (e.g.
36.87998/-88.3435). The map or plat must contain enough detail so that each golden eagle nest proposed to be taken can
be readily located by the Service. For assistance determining the latitude/longitude for a specific location in decimal
degrees, please visit https://earthexplorer.usgs.gov/.
b) A map and digital photographs that show the location of the nest in relation to buildings, infrastructure, and human activities.
c) A map with the location of the property, including city, county and State

2) Any permit issued as a result of this application is not valid unless you also have any required State or tribal
permits or approvals associated with the activity. Have you obtained all required State or tribal permits or
approvals to conduct this activity?

Yes, Have Attached
None Required

Have Applied, Will Provide Upon Request

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Form 3-200-18 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

3) Describe the resource development or recovery operation in which you are engaged.

4) Indicate the number of golden eagle nests you propose to take and how they were determined to be inactive. Provide
copies of the monitoring report(s) indicating nest is inactive.

5) Describe the property on which the taking is proposed, with reference made to its exact geographic location.

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Form 3-200-18 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

6) Describe each activity to be performed during the resource development or recovery operation that involves the taking of a
golden eagle nest.

7) Indicate the length of time you need the permit to be valid, including the start and ending dates of the resource
development or recovery operation. The permit cannot be valid for a tenure of longer than 2 years.

8) What is the intended disposition of each nest you propose to take? Are you willing to donate any nests for scientific or
educational purposes?

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Form 3-200-18 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

9) Provide a statement indicating any proposed mitigation measures that are compatible with the resource development or
recovery operation to encourage golden eagles to reoccupy the site. If the establishment of one or more nest sites is
proposed, provide a description of the materials and methods to be used and the exact location of each artificial nest site.
Mitigation measures may include reclaiming disturbed land to enhance golden eagle nesting and foraging habitat,
relocating in suitable habitat any inactive golden eagle nest taken, or establishing one or more nest sites.

10) You must retain records legibly written or reproducible in English relating to the activities conducted under your
permit for at least 5 years after the date of expiration of your permit. Is the physical address you provided in Section
C on page 1 of this application the address where your records will be kept?

Yes
No, If "No" provide
the physical address

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Form 3-200-18 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

11) 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.

12) Are you eligible for Fee Exempt Status? Fee exempt status applies to government agencies (Federal, State, Tribal,
and municipal governments). Applicants acting on behalf of such agencies must submit a letter on agency letterhead
and signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the
applicant will be carrying out the permitted activity for the agency, or the agencies tax exempt form.
Yes - Government Agency
Yes - Acting on behalf of Government Agency
Documentation Included
No - not eligible for Fee Exempt Status
13) I acknowledge that I have read the form Instructions and FAQ, and have accessed the page with the Return Addresses to
obtain the address where I should return this form. I have also filled out all fields and questions in this application. Check
this box to acknowledge:
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Form 3-200-18 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

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), 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 to average 10 hours for the application and 30 minutes for recordkeeping,
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/PERMA (JAO), 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 non-confidential
summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

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