Form 3-200-40 Application - Export and Re-import of Museum Specimens (

FWS Form 3-200-40 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires ##/##/####

EXPORT AND RE-IMPORT OF MUSEUM SPECIMENS (U.S. Endangered Species Act)
☐New

☐Reissue/Renew ☐Amendment

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C.**
A. Complete if applying as an individual
1.a. Last name
2 Date of birth
(mm/dd/yyyy)

5.a. Telephone number

1.b. First name
5.b. Alternate telephone
number

1.c. Middle name or initial

1.d. Suffix

6. E-mail address

B. 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.a. Description of business, agency, Tribe, or institution

4.a. Principal officer (P.O.) last name 4.b. P.O. first name

4.c. P.O. middle initial

5. Primary contact name

6. Primary e-mail address

7.a. Business telephone number

7.b. Alternate phone no.

3.b. Website URL (if applicable)
4.b. P.O. Title

8.a. Primary contact telephone no.

C. 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.e. County/Province

1.f. Country

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. Include a check or money order, payable to the U.S. FISH AND WILDLIFE SERVICE, a nonrefundable processing fee (see the fee
schedule). Federal, Tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the
processing fee – attach documentation of fee exempt status as outlined in instructions. (50 CFR 13.11(d))
2.
3.

If you are requesting a reissue/renew/amendment, what is your permit/file number?
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.

The individual/principal officer of the business must print and sign the application. (No photocopied or stamped signatures)

Date (mm/dd/yyyy)

** Click here for additional instructions on completing the above form (link to instruction page). See the last page for information on the Privacy Act,
Paperwork Reduction Act, Estimated Burden, and Freedom of Information Act aspects of this application form.
Mail your application(s) to Division of Management Authority, Branch of Permits, MS:IA 5275 Leesburg Pike, Falls Church, VA 22041-3803.
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FWS Form 3-200-40 (Rev. 01/2020)
U.S. Department of the Interior

E.

OMB Control No. 1018-0093
Expires ##/##/####

EXPORT AND RE-IMPORT OF MUSEUM SPECIMENS (U.S. ENDANGERED SPECIES ACT)

Note 1: An ESA museum permit only authorizes export and re-import of specimens currently accessioned in your
museum. If specimens of species are protected by CITES, Marine Mammal Protection Act, Migratory Bird Treaty Act, or
Bald and Golden Eagle Protection Act, you are required to obtain additional authorizations prior to any export or re-import
of specimens. Contact DMA for the required application.
Note 2: For the export or re-import of specimens of ESA-listed species that are not part of your museum collection or
have not yet been collected, please submit Form 3-200-37.
For renewals, include the original permit and the annual report (see Form 3-200-40a). The report is a summary of all
exports and re-imports conducted under your permit for the past year, including species’ scientific name and common
name of specimen sent or received, date of activity, acquisition number, description, receiving/sending institution, and
country.

1. Name and address where you wish the permit to be mailed, if different from page 1. If you would like
expedited shipping, please enclose a self-addressed, pre-paid, computer-generated, courier service airway
bill. If unspecified, all documents will be mailed via regular mail through the U.S. Postal Service.

2. Who should we contact if we have questions about the application (name, phone number, and e-mail)?

3. Have you or any at your institution, been assessed a civil penalty or convicted of any criminal provision of any
statute or regulation relating to the activity for which the application is filed; 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; forfeited collateral; OR are currently under charges for any violation of the
laws mentioned above?
___No

___ Yes

If you answered “Yes” to Question 3, provide: a) the individual’s name; b) date of charge; c) charge(s); d) location
of incident; e) court, and f) action taken for each violation. Please be aware that a “Yes” response does not
automatically disqualify you from getting a permit.

4. This is for a
___ New application
___ Renewal/Amendment of Permit # __________________
5. If relevant information about the requesting institution or collection is available online, please provide the URL:
__________________________________________
6. Is the institution or collection accredited by an organization such as the Index Herbarium or American Alliance
of Museums:
___ Yes. Indicate the name of the accrediting organization(s) and provide supporting documentation,
such as a website, copy of accreditation, or other such evidence.

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FWS Form 3-200-40 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires ##/##/####

___ No. Provide copies or other evidence of information related to the institution’s standards for scientific
integrity, record-keeping, accessibility to, and management of the collection.
7. Are the collections and associated data permanently housed and professionally curated? If yes, how long
have the collections been permanently housed and professionally curated. Provide the physical address for
the collection and the name and contact information for the curator.
___ YES

___ NO

8. Are all accessions properly recorded in a permanent catalogue?
___ YES (If catalogue or collection is available online, provide the URL _______________________.
___ NO
9. As appropriate, ENTER approximate number of accessioned specimens:
___ Mammals

___ Birds

___ Insects/Arachnids

___ Other Invertebrates

___ Reptiles/Amphibians

___ Vascular Plants

___ Fish

___ Non-vascular Plants

___ Other (provide description:________________________________)
10. Do you maintain any specimens of species protected under the Marine Mammal Protection Act?
___ YES

___ NO

a.

If "yes," do you intend to export or re-import these specimens? _______

b.

If “yes”, provide a copy of your MMPA authorization for this activity.

11. Do you maintain or intend to obtain any specimens of species protected under CITES?
___ YES

___ NO

a.

If "yes", do you intend to export or re-import these specimens? _______

b.

If “yes”, provide a copy of your CITES authorization for this activity.

12. Do you maintain or intend to obtain any specimens of species protected under the Migratory Bird Treaty Act?
___ YES

___ NO

a.

If "yes", do you intend to export or re-import these specimens? _______

b.

If “yes”, provide a copy of your MBTA authorization for this activity.

13. Do you maintain any specimens of species protected under the Bald and Golden Eagle Protection Act?
___ YES

___ NO

a.

If "yes", do you intend to export or re-import these specimens? _______

b.

If “yes”, provide a copy of your BGEPA authorization for this activity.

14. Are specimens accessible to qualified users from outside your institution?
___ YES

___ NO

ENTER approximate number

In the United States

Outside the United States

Loans last year
Exchanges last year
Donations last year

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FWS Form 3-200-40 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires ##/##/####

15. Are permanent records maintained on specimens that are loaned or transferred?
___ YES

___ NO

16. Are specimens acquired primarily for the purpose of research, the results of which are to be reported in
scientific publications?
___ YES

___ NO

17. Are specimens prepared and the collections arranged in a manner that ensures their accessibility?
___ YES

___ NO

18. Are data on specimen labels, permanent catalogues, and other records as accurate as possible?
___ YES

___ NO

19. To the best of your knowledge, were the specimens in the collection acquired legally under the relevant laws
of the country where they were obtained and the United States (e.g., import permits, collection permits, take
permits, landowner permission)?
___ YES

___ NO

20. Are all specimens of endangered and threatened species permanently and centrally housed under direct
control of the scientific institution?
___ YES

___ NO

21. Are all specimens of endangered and threatened species intended for exchange managed in such a manner
to preclude their use solely as decorations or trophies, or for other purposes incompatible with the principles
of the ESA?
___ YES

___ NO

22. Please ATTACH (or enter below) a statement of how the activities carried out by your institution will enhance
or benefit the endangered or threatened species intended for exchange (e.g., identify recovery tasks from the
recovery plan, or describe how the research activities will benefit the species under the Act).

All international shipment(s) must be through a designated port. A list of designated ports (where an inspector is
posted) is available. If you wish to use a port not listed, please contact the Office of Law Enforcement for a
Designated Port Exemption Permit (Form 3-200-2).

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FWS Form 3-200-40 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0093
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 Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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 which
affect protected species. This helps 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
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) in order provide the U.S. Fish
and Wildlife Service the information necessary, under the applicable laws governing the requested activity, for which a
permit is requested. 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 applicable 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. 1018-0093.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 2 hour
Amended submission - paper-based: 45 minutes
Original submission - electronic: 45 minutes
Amended submission - electronic: 30 minutes
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/PERMA
(JAO), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed form to this
address.

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