Form 3-200-52 Application - Reissuance, Renewal, or Amendment of a Per

FWS Form 3-200-52 (Rev. 07/2020) OMB Control No. 1018-0093

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

REISSUANCE, RENEWAL, OR AMENDMENT OF A PERMIT

☐ 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.^**

Complete if applying as an individual
1.a. Last name			1.b. First name		1.c. Middle name or initial	1.d. Suffix
2 Date of birth (mm/dd/yyyy)	5.a. Telephone number	5.b. Alternate telephone number		6. 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.a. Description of business, agency, Tribe, or institution				3.b. Website URL (if applicable)
4.a. Principal officer (P.O.) last name	4.b. P.O. first name		4.c. P.O. middle initial		4.b. P.O. Title
5. Primary contact name			6. Primary e-mail address
7.a. Business telephone number		7.b. Alternate phone no.		8.a. Primary contact telephone no.

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	2.c. State	2.d. Zip code/Postal code	2.e. County/Province	2.f. Country

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

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.

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.

E. REISSUANCE, RENEWAL, OR AMENDMENT OF A PERMIT (For this application, all permits, registrations, and certificates are referred to as a permit.)

NOTE 1: If you are renewing your Designated Port Exemption permit, use form 3-200-2 and submit to appropriate Office of Law Enforcement address. If you are renewing your Import/Export license (required for commercial activities), use form 3-200-3 and submit to appropriate Office of Law Enforcement address.

NOTE 2: This form cannot be used for a lost or damaged permit. If you need to replace a lost or damaged permit, please use form 3-200-66. The application must be submitted to the office that issued the initial permit. Lost or damaged permit

NOTE 3: Some activities, such as all master files for multiple shipments, Certificate of Scientific Exchange (COSE), circus/traveling exhibits, and artificially propagated plants, can only be re-issued, renewed, or amended by submitting a new application for permits for those activities. Please refer to these application types to determine if another application form would be more appropriate or contact the Division of Management Authority for more information.

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 of the owners of the business (if applying as a business, corporation, or 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.

PRT#:

4. Permit number. Enter the permit number to be reissued/renewed/amended.

5. Submit the original permit with this application.

6. Past activities.

1. Provide copies of all cleared documents and form 3-177 (FWS declaration of wildlife) associated with this permit.

2. Provide a summary detailing activities conducted under this permit, as well as a brief statement of why you are seeking reissuance/renewal.

7. Annual Report. If required by your permit, provide an annual report as conditioned (Please disregard if you have already submitted your annual report.)

8. Sport-hunted trophies: If you did not hunt during the hunting season stated in your original application, you are not eligible for a renewal. Please submit a new application form.

9. Certification - Complete one of the statements below and supply any additional documentation requested: (original signature is required)

1. For NO CHANGES to original application:

I certify that the information submitted in support of my original application for the permit indicated above has not changed and is still currently correct. I hereby request reissuance or renewal of this permit.

Permittee’s signature: ____________________________________ Date: ___________

2. For CHANGES to original application:

On an attached page(s), provide a complete description of any changes (e.g., change in principal officer, personnel, address, location of activities, types of activities). Please sign each attached page. Also note that we need to request additional information regarding the changes after reviewing your initial request.

I certify that the information submitted in support of my original application for the permit indicated above is still currently correct EXCEPT for the changes noted on the attached, signed page(s). I hereby request re-issuance or renewal of this permit with the indicated changes.

Permittee’s signature: ____________________________________ Date: ___________

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).

CITES Permit Offices

NOTE: The application must be submitted to Division of Management Authority or to the Office of Law Enforcement in the region where the applicant is located.

Division of Management Authority (DMA)

5275 Leesburg Pike, MS-IA

Falls Church, VA 22041-3803

Office of Law Enforcement (OLE)

Anchorage

U.S. Fish & Wildlife Service

Office of Law Enforcement

P.O. Box 190045

4600 Postmark Drive, Suite NB207

Anchorage, AK 99519

Phone: (907) 271-6198

Fax: (907) 271-6199

Atlanta

U.S. Fish & Wildlife Service

Office of Law Enforcement

4341 International Parkway, Suite #104

Atlanta, GA 30354

Phone: (404) 763-7959

Fax: (404) 366-7031

Blaine, WA

U.S. Fish & Wildlife Service

Office of Law Enforcement

9925 Pacific Highway, Room 136

Blaine, WA 98230

Phone: (360) 332-5388

Fax: (360) 332-3010

Chandler, AZ

U.S. Fish & Wildlife Service

Office of Law Enforcement

2545 W. Frye Road, Suite 8
Chandler, AZ 85224-6273
Phone: (480) 967-2007
Fax: (480) 966-9766

Denver, CO

U.S. Fish & Wildlife Service

Office of Law Enforcement

Denver International Airport

P.O. Box 492098

Denver, CO 80249

Phone: (303) 342-7430

Fax: (303) 342-7433

Fairbanks

U.S. Fish & Wildlife Service

Office of Law Enforcement

1412 Airport Way

Fairbanks, AK 99701

Phone: (907) 456-2335

Fax: (907) 456-2356

Guam

U.S. Fish & Wildlife Service

Office of Law Enforcement

415 Chalan San Antonio Road, Suite 209

Tamuning, Guam 96913-3620

Phone: (671) 647-6064

Fax: (671) 647-6068

Honolulu, HI

U.S. Fish & Wildlife Service

Office of Law Enforcement

3375 Koapaka St., #B296

Honolulu, HI 96819-1867

Phone: (808) 861-8525

Fax: (808) 861-8515

Los Angeles

U.S. Fish & Wildlife Service

Office of Law Enforcement

370 Amapola Ave., #114

Torrance, CA 90501

Phone: (310) 328-6307

Fax: (310) 328-6399

Miami

U.S. Fish & Wildlife Service

Office of Law Enforcement

3701 NW 82nd Avenue, Ste #1

Doral, Florida 33166

Phone: (305) 526-2994 or 2620

Fax: (305) 526-7480

New Orleans

Mail:

U.S. Fish & Wildlife Service

Office of Law Enforcement

61387 Hwy 434

Lacombe, LA 70445

Physical:

U.S. Fish & Wildlife Service

Office of Law Enforcement

2424 Edenborn, Room 100

Metairie, LA 70001

Phone: (504) 219-8870

Fax: (504) 219-8868

Portland, OR

U.S. Fish & Wildlife Service

Office of Law Enforcement

P.O. Box 55206

Portland, OR 97238

Phone: (503) 231-6135

Fax: (503) 231-6133

Rosemont, IL

U.S. Fish & Wildlife Service

Office of Law Enforcement

10600 Higgins Road, Suite 200

Rosemont, IL 60018

Phone: (847) 298-3250 Ext. 110

Fax: (847) 298-7669

San Francisco

1633 Old Bayshore Highway, Ste 248

Burlingame, CA 94010

Phone: (650) 876-9078

Fax: (650) 876-9701

Seattle

U.S. Fish and Wildlife Service

Office of Law Enforcement

17930 International Blvd. Suite 500

Seatac WA 98188

Valley Stream, NY

U.S. Fish & Wildlife Service

Office of Law Enforcement

70 E. Sunrise Hwy, Suite 419

Valley Stream, NY 11580

Phone: (516) 825-3950

Fax: (516) 825-3597

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 to average 15 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.

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