Form 3-200-19 Application - Import of Sport-hunted Trophies of Souther

FWS Form 3-200-19 (Rev. 01/2020)
U.S. Department of the Interior

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

IMPORT OF SPORT-HUNTED TROPHIES OF SOUTHERN AFRICAN LEOPARD AND
NAMIBIAN SOUTHERN WHITE RHINOCEROS
☐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 3-200-19 (Rev. 01/2020)
U.S. Department of the Interior

E.

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

IMPORT OF SPORT-HUNTED TROPHIES OF SOUTHERN AFRICAN LEOPARD AND NAMIBIAN
SOUTHERN WHITE RHINOCEROS

Note 1: If you hold an import permit for trophy/trophies that you did not use, please return the unused original
permit to the address on page one.
Note 2: If you are requesting reissuance of a permit because you have taken a trophy, but were unable to import
it prior to the expiration of the permit, please use the renewal form (3-200-52) and return your original permit with
that form.
Note 3: Sport-hunted trophy is defined at 50 CFR 23.74 as follows: Sport-hunted trophy means a whole dead
animal or a readily recognizable part or derivative of an animal specifically identified on the accompanying CITES
document that meets the following criteria:
•
•
•
•

Is raw, processed, or manufactured;
Was legally obtained by the hunter through hunting for his or her personal use;
Is being imported, exported, or re-exported by or on behalf of the hunter as part of the transfer from its
country of origin ultimately to the hunter's country of usual residence; and
Includes worked, manufactured, or handicraft items made from the sport-hunted animal only when:
i.
Such items are contained in the same shipment as raw or tanned parts of the sport-hunted animal
and are for the personal use of the hunter;
ii.
The quantity of such items is no more than could reasonably be expected given the number of
animals taken by the hunter as shown on the license or other documentation of the authorized hunt
accompanying the shipment; and
iii.
The accompanying CITES documents (export document and, if appropriate, import permit) contain a
complete itemization and description of all items included in the shipment.

Note 4: Certain hunting trophies, including leopard and rhinoceros hunting trophies, are subject to restrictions on
their use after import into the United States. Please see 50 CFR 23.55 for more information or contact the Division
of Management Authority.
•
•
•
•

Complete all questions on the application.
Mark questions that are not applicable with "N/A".
If applying for more than one trophy species, be sure to answer questions 5 and 6 for each trophy.
If importing trophies from more than one country, you must submit a separate application for
each shipment in order to obtain separate import permits.

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 the U.S. Postal Service.

2.

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

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FWS Form 3-200-19 (Rev. 01/2020)
U.S. Department of the Interior

3.

OMB Control No. 1018-0093
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Have you or your client (if a broker applying on behalf of your client), 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.

ENTER the quantity and sex (if known) next to the name of the species you are applying to import (you may
apply to import specimens of more than one species provided they have been/are being hunted in the same
country):

a.

Leopard (Panthera pardus) Quantity: ____ Sex (if known): ____ (Limited to the import of two
per calendar year). If you wish to import a leopard taken in northern or western Africa, please use
form 3-200-20.

b.

Southern white rhinoceros (Ceratotherium simum simum) from Namibia
Quantity: ____ Sex (if known): ____ (An import permit is not required for trophies
harvested in South Africa or Swaziland. If you are looking to import from a different
country, please use Form 3-200-20).

5. IF ANIMAL IS CURRENTLY LIVING IN THE WILD, Please enter the following information:
a.

Country and place (area, region, GIS coordinates, ranch, conservancy, management area, or
hunting block, AND nearest city) where wildlife is to be taken from the wild:

b.

Date wildlife is to be hunted:

c.

Name of hunting outfitter, safari company, or professional hunter you will be hunting with:

6. IF THE ANIMAL HAS ALREADY BEEN TAKEN, please enter the following:

a. Country and location (area, region, GIS coordinates, ranch, conservancy, management area, or hunting
block, AND nearest city) where wildlife was taken from the wild:

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FWS Form 3-200-19 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0093
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b. Date wildlife was hunted:
c. Approximate age of animal:
d. Name of hunting outfitter, safari company, or professional hunter you hunted with:

e. The current location of the trophy (address and country) [the U.S. CITES import permit will identify this
country as the country of export/re-export and must match with the CITES export/re-export document]:

7. Please provide a copy of any applicable foreign government permits or licenses that were required to
remove this animal from the wild (if you have not hunted yet and do not currently hold any such permits or
licenses, please indicate so).
8. Complete name and address of overseas person or business shipping the trophy to you. If you are
applying to import a trophy directly from Namibia, you must provide the name and address of the
professional hunter listed on your Namibian hunting permit [this name will appear on the face of the export
permit].
Name:
Business Name:
Address:
Address:
City:
State/Province:
Country, Postal Code:
CERTIFICATION STATEMENT (original signature must be provided for either 9 or 10 below)
9. If you are a broker or taxidermist applying on behalf of a U.S. hunter or foreign national, provide
documentation to show you have a Power of Attorney to act on your client’s behalf and sign the following
statement.
I acknowledge that the sport-hunted trophy/trophies to be imported has been/will be personally hunted
by my client and is being imported only for my client's personal use (i.e., not for sale, transfer,
donation, or exchange that is reasonably likely to result in economic use, gain, or benefit). If
applying for the import of a leopard trophy, I understand that my client may only import two leopard
trophies in one calendar year.

Taxidermist/Broker’s signature: _________________________________ Date: ______

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FWS Form 3-200-19 (Rev. 01/2020)
U.S. Department of the Interior

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

10. If you are the hunter applying to import your own trophy, please read and sign the following statement.

I acknowledge that the sport-hunted trophy/trophies to be imported has been/will be personally hunted
by me and is being imported only for my personal use (i.e., not for sale, transfer, donation, or
exchange that is reasonably likely to result in economic use, gain, or benefit). If applying to import
a leopard trophy, I understand that I may only import two leopard trophies in one calendar year.

Applicant's signature: _________________________________________ Date: _______

Be aware that there may be additional permitting or approval requirements by your local or state
governments, as well as required by other Federal agencies or foreign government to conduct your
propose activity. While the Service will attempt to assist where possible, it is your responsibility to obtain
such approval.

11. All international shipment(s) must be through a designated port. A list of designated ports (where an inspector is
posted) is available from the list of designated ports. 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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OMB Control No. 1018-0093
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FWS Form 3-200-19 (Rev. 01/2020)
U.S. Department of the Interior

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 15 minutes (electronically) to 20 minutes (paperbased), 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.

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