Form 3-200-23 Application - Export of Pre-Convention, Pre-Act, or Anti

OMB Control No. 1018-0093
Expires 08/31/2023

FWS Form 3-200-23 (Rev. 05/2022)
U.S. Department of the Interior

EXPORT OR RE-EXPORT OF PRE-CONVENTION, PRE-ACT, OR ANTIQUE SPECIMENS
(CITES, MMPA or ESA)
☐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 [50 CFR
13.11(d)(4)]. 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)

** Further instructions for the above application may be found on our ePermits website. 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 3-200-23 (Rev. 05/2022)
U.S. Department of the Interior

E.

OMB Control No. 1018-0093
Expires 08/31/2023

EXPORT OR RE-EXPORT OF PRE-CONVENTION, PRE-ACT, OR ANTIQUE SPECIMENS (CITES, MMPA OR ESA)
Description
pre-Convention
(CITES)

Applicable Date
Specimen was acquired (removed from the wild or born or propagated in a controlled
environment) before the date CITES applied to it. The CITES listing date can be found at
http://www.cites.org.
pre-Act
Specimen was held in a controlled environment on or before (a) December 28, 1973 or the date
when the species was listed under the ESA, and (b) the holding or use was not in the course of a
(ESA)
commercial activity (e.g., it has not been bought, sold, or offered for sale by you or anyone else)
since December 28, 1973, or the date when listed under the ESA.
Antique
Specimen is not less than 100 years old, has not been repaired or modified on or after December
(ESA)
28, 1973 with any part of any species protected by ESA and a) has entered at a port 1 designated
for the import of ESA antiques or b) there is documented proof that the specimen was in the
United States prior to September 22, 1982.
pre-MMPA
Specimen was taken prior to December 21, 1972.
CITES - Convention on International Trade in Endangered Species of Wild Fauna and Flora
MMPA – Marine Mammal Protection Act
Act or ESA – Endangered Species Act
Provide the following information. Complete all questions on the application. Mark questions that are not applicable
with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you submit, indicate
the application question number you are addressing.
Note 1: For shipment of Brazilian rosewood (Dalbergia nigra), submit form 3-200-32.
Note 2: Finished products of some timber species, such as big leaf mahogany, are not covered under CITES (only logs,
sawn timber, and veneer), while other finished products of species require CITES documents. If you want to
export furniture or other finished products containing CITES-listed wood, please contact the Division of
Management Authority to determine if a CITES document is required.
Note 3: For fossilized walrus ivory removed from the wild after 1972, please use form 3-200-27.
Note 4: African elephant ivory: Raw ivory cannot be re-exported. Worked ivory that qualifies as an antique may be
exported. For non-commercial exports, antique worked ivory may also be exported. In addition, worked ivory that
was removed from the wild before February 4, 1976, and is part of either a household move or an inheritance
could qualify to be exported. (For export of worked African elephant ivory that is contained in a musical
instrument, please use form 3-200-88; for worked African elephant ivory that is part of a traveling exhibition,
please use form 3-200-30). Please review our webpage “What Can I Do With My Ivory?” for important guidance
and reminders.
Electronic submission of inventories, photographs, and receipts: If you wish to provide information electronically, please
include a flash drive containing this information with your physical application.

1 U.S. Customs and Border Protection (CBP) designated 13 ports for the entry of antiques made of ESA-listed species on September 22, 1982 (19
C.F.R. 12.26). The following ports are authorized: Boston, Massachusetts; New York, New York; Baltimore, Maryland; Philadelphia, Pennsylvania;
Miami, Florida; San Juan, Puerto Rico; New Orleans, Louisiana; Houston, Texas; Los Angeles, California; San Francisco, California; Anchorage, Alaska;
Honolulu, Hawaii; and Chicago, Illinois.

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OMB Control No. 1018-0093
Expires 08/31/2023

FWS Form 3-200-23 (Rev. 05/2022)
U.S. Department of the Interior

1. Name and address where you wish the permit to be mailed, if different from physical address. 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 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. Type of Activity:

__ Export
__ Re-export (e.g. exporting a specimen that was previously imported into the United States)

5. For EACH specimen being exported/re-exported, please provide the following: (You may submit as a separate
document, as long as the information is provided as outlined in the table.)
Scientific name (genus,
species, and, if
applicable, subspecies)

Common
Name

Qty.

Description of Item (e.g.,
published description from a
catalog or art book)

Size (include
unit of
measurement)

Date of
Manufacture

Date of acquisition
(e.g., bill of sale, U.S.
Customs import
declaration, transferred
document)

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OMB Control No. 1018-0093
Expires 08/31/2023

FWS Form 3-200-23 (Rev. 05/2022)
U.S. Department of the Interior

6. Provide the current location of specimen(s) (address and country):
Name:
Address:
City:
State/Province:
County, Postal Code:
7. What is the purpose of the export?

__ Commercial __ Personal
__ Scientific

__ Other (specify) ______________________

__ Exhibition

8. Name and address of foreign recipient
Name:
Address:
City:
State/ Province:
County, Postal Code:
9. If protected under CITES, provide documents, signed statement, or other evidence that the specimen(s) was
obtained or manufactured prior to the date CITES applied to the item (see pre-Convention definition above).
10. For specimens(s) protected under the U.S. Endangered Species Act (ESA), provide one of the following:
a. For Antiques (see definition above):
i.

Provide documentation which shows the age of the item OR a statement from a qualified appraiser
attesting to the age;

ii.

Signed statement that the item has not been repaired or modified on or after December 28, 1973 with
any part of any species protected by ESA, AND

iii. Documentation showing that the specimen either was imported through a designated antiques port or
was in the United States before September 22, 1982 (the date the antiques ports were established).
b. For the non-commercial export of worked African elephant ivory that is part of a household move or
inheritance and is not an antique, please provide the following:
i.

Documentation that shows that the ivory used in the specimen was removed from the wild before
February 4, 1976 (this may consist of a statement from a qualified appraiser or family
documentation), and

ii.

If the export is part of a household move, documentation on when the specimen was acquired and
how long the specimen has been in your possession OR

iii. If the export is part of an inheritance, documentation on the inheritance, such as a will or legal
documents.
c.

For the export of all other items that are less than 100 years old (see pre-Act definition above) and that are
not African elephant ivory:
Has this item entered into commerce (e.g., been bought, sold, or offered for sale by you or anyone else)
since December 28, 1973?
i.

If Yes, you must complete form 3-200-37.

ii.

If No, sign the following certification:
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FWS Form 3-200-23 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires 08/31/2023

CERTIFICATION STATEMENT original signature is required
I certify to the best of my knowledge and belief that each of the items identified in question 5 that qualify under
question 10(c) was 1) held in captivity or in a controlled environment on December 28, 1973, or the species
listing date, if later; 2) that the purposes of such holding were not contrary to the purposes of the Act; and 3)
that the wildlife was not held in the course of a commercial activity (if you have questions about this certification
statement, please contact the Division of Management Authority).
Applicant's signature: ________________________________________ Date: ____________________
11. If the specimen is protected under the Marine Mammal Protection Act, provide an affidavit and supporting
documentation that the item was taken prior to December 21, 1972, as outlined in 50 CFR 18.14. For cetacean
(whales) and pinniped (seals and sea lions; not walrus) specimens, provide either a copy of NOAA Fisheries letter
of authorization or evidence that NOAA Fisheries has been contacted.
12. If Re-export provide:
a.

A copy of canceled CITES export or re-export document issued by the appropriate CITES office in the
country from which the wildlife was imported; and

b.

Cleared Wildlife Declaration for Import form 3-177, animal only.

13. Is this shipment a sample collection being exported for temporary exhibition or display purposes and
accompanied by a valid ATA carnet?
__ No

__ Yes - provide ATA carnet document number ___________________

14. For live animals, the transport conditions must comply with the CITES Guidelines for Transport of Live Animals
or, in the case of air transport, with the International Air Transport Association (IATA) live animal regulations
(contact airline for information). As such, describe:
a.

The type, size, and construction of any shipping container; and,

b.

The arrangements for watering or otherwise caring for the wildlife during transport.

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

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OMB Control No. 1018-0093
Expires 08/31/2023

FWS Form 3-200-23 (Rev. 05/2022)
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 to average 45 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: BPHC, 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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