3-2405 Self-Clearing Check-In Permit

FWS Form 3-2405 (Rev. 04/2022) OMB Control No. 1018-0140

U.S. Department of the Interior Expires ##/##/20##

Self-Clearing Check-in Permit

You must complete the Check-In portion of this daily permit and put it in the permit box before engaging in any activity on the Refuge/Hatchery.

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U. S. Fish and Wildlife Service

(Refuge/Hatchery will insert refuge name)

Each user must [carry/display on dash] the Daily Visitor Registration portion while on the Refuge/Hatchery. At the conclusion of your visit, complete the following information and put this portion in the permit box.

Number of hours spent on Refuge _____

Number of hunt days spent on Refuge _____ (on final day of hunting activities)

Hunter Harvest Information: (Please check all that apply)

(Option 1:) Did you harvest any wildlife? Yes No

How many did you harvest? _____ (Example: Squirrel 3)

(Option 2:)

What were you hunting? How many did you harvest?

(Check all that apply) (Put Zero “0” if no game harvested)

(Example: Squirrel _3_ Deer _0_)

Game Species

(Each Refuge will list relevant species with a space for the number harvested

and other relevant data required.)

Incidental Species

(Each Refuge will list relevant incidental species and other relevant data

required.)

Method:

(Each Refuge will list allowable methods of harvest.)

Angler Harvest information:

(Each Refuge will list relevant species and other relevant data required.)

Did you observe:

(Each Refuge will list relevant species.)

NOTICES

Privacy Act Statement

Authority: The information requested is authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) as amended and the Refuge Recreation Act (16 U.S.C. 460k – 460k-4, 640K-3, & 664).

Purpose: The collection of personal information is to verify that an individual is eligible to receive a permit to conduct monitored activity on areas within the National Wildlife Refuge System, national fish hatcheries, and other conservation areas administered by the Secretary of the Interior for fish and wildlife purposes.

Routine Uses: The individual’s information will be used to verify permit status, provide permittees with permit-related information, and monitor activities conducted under a permit. This information may be shared in accordance with the Privacy Act of 1974 and the routine uses listed in the System of Records Notices: FWS-5 National Wildlife Refuge Special Use Permits; FWS-21 Permits System; FWS-10 National Fish Hatchery Special Use Permits.

Disclosure: Providing the information is voluntary; however, as a requirement for maintaining a Federal permit under the National Wildlife Refuge System Administration Act, failure to disclose the requested information may be sufficient cause for revocation of the permit.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) to evaluate the qualifications, determine eligibility, and document permit applicants, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. This information is required in order to obtain or retain a benefit; however, failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. 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 information collection and assigned control number 1018-0140.

Estimated Burden Statement

Public reporting for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed application to this address.

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Self-Clearing Daily Vehicle Permit

Each user must enter the date and, while on the Refuge, display this tag in the vehicle in clear view.

VEHICLE TAG

Other Side Face-up

Self-Clearing Check-in Permit

U. S. Fish and Wildlife Service

(Refuge/Hatchery will insert refuge name)

Date __________________ (pre-coded) Permit # _____________

Name: _________________________ Ph#: ____________Cell#: ____________

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Self-Clearing Daily Visitor Registration Permit

Each user must complete the following information and [carry this portion/display on dash] while on the Refuge. At the conclusion of your visit, complete the information on the reverse side and put this portion in the permit box.

Date __________________ (pre-coded) Permit # _____________

State Issued Hunter Ident./License No.: _____________________

Name

City State Zip Code

Vehicle License Plate No: ___________ State Issued: ___

Purpose of Visit: (Please check all that apply)

Hunting Birding Wildlife Observation Photography Auto Touring Fishing Hiking ^{Boating/Canoeing Visitor Center Special Event}

^{Environmental Education Class Volunteering}

Number of hours spent on Refuge _____

Number of hunt days spent on Refuge _____ (at final day of hunting activities)

Other Recreation (please specify):

___________________________________________________________________

Refuge Unit(s) Visited:

___________________________________________________________________

Map of Refuge or Refuge Unit(s)

(Refuge will insert a map of the refuge)

Comments:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Self-Clearing Daily Vehicle Permit

Date: _ (pre-coded) Permit # _

If there is more than one person in the vehicle, there must be a tag for each user displayed in the vehicle in clear view.

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