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pdfFWS Form 3-200-29 (Rev. 01/2020)
U.S. Department of the Interior
OMB Control No. 1018-0093
Expires ##/##/####
EXPORT/RE-EXPORT OF WILDLIFE SAMPLES AND/OR BIOMEDICAL SAMPLES (CITES)
☐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 3-200-29 (Rev. 01/2020)
U.S. Department of the Interior
OMB Control No. 1018-0093
Expires ##/##/####
E. Export/Re-Export of Wildlife Samples and/or Biomedical Samples (CITES)
For the export/re-export of samples from species listed under the Endangered Species Act or CITES
Appendix I species (50 CFR Part 17), use application form 3-200-37.
The U.S. FWS may not be able to issue CITES documents for the commercial export of Appendix-I
specimens, unless the specimens were obtained from animals produced at a CITES-registered Appendix-I
commercial breeding operation. For more information on registering an Appendix-I commercial breeding
operation, contact the Division of Management Authority at [email protected].
Use this form if you are collecting in the open ocean on a U.S. registered vessel and transporting the
specimens directly to a different country - your shipment would require a U.S. CITES export permit. In
addition, if you are exporting Appendix-I specimens, an import permit issued by the country into which the
specimens are transported would be required.
This application can be used to:
☐ Request a single-use permit for export of samples that is valid for 6 months from the date of
issuance. For re-issuance or amendment of a single use permit, the original permit must be returned with this
completed application form.
☐
Request a single-use permit for re-export of samples [e.g., samples that were previously
imported into the United States or taken from animals previously imported] that is valid for 6 months
from the date of issuance. For re-issuance or amendment of a single use permit, the original permit must be
returned with this completed application form.
☐
Establish a Master File: A “Master File” can be valid for up to 3 years from the date of issuance. Once
the Master File is approved, you must obtain partially completed certificates to export or re-export samples.
Partially completed certificates are $5 each, are valid for 6 months. Certificates must be obtained prior to
making any shipment and must accompany the shipment.
☐
Amend an existing Master File: A “Master File” must be amended when there have been any
changes to the information provided in the original application for a master file. You need only provide the
requested information for the changes that need have occurred. However, if you intend to renew your current
Master File at the same time you are amending it, see below.
☐
Renew (or Amend and Renew) a Master File: To renew a Master File that has or will soon expire, you
must complete this entire application, including providing all of the information requested in this form for all
specimens to be included in your Master File and information on any changes to your facility, operations,
species, or suppliers for the specimens that you wish to export.
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.
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FWS Form 3-200-29 (Rev. 01/2020)
U.S. Department of the Interior
OMB Control No. 1018-0093
Expires ##/##/####
Provide the following information. Complete all questions on the application. Mark questions that are not
applicable with "N/A". If needed, use separate sheets of paper. On all attachments or separate sheets you
submit, indicate the application question number you are addressing. If you are applying for multiple
specimens, be sure to indicate which specimen you are addressing in each response.
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 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. If requesting a single-use permit or master file with only one recipient, provide the name and address of
foreign recipient (if shipping to yourself, include your foreign address):
NOTE: Providing a foreign recipient is not required if establishing a master file.
Name:
Business Name:
Address:
Address:
City:
State/Province:
Country, Postal Code:
5. Number of partially completed certificates requested at this time: ______ ($5 each)
If requesting renewal, amendment, or establishment of a Master File, please be aware that partially completed
permits must be issued from the master file in order to ship the requested specimen(s).
Partially completed certificates may additionally be requested by submitting form 3-200-74 from a valid Master File.
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FWS Form 3-200-29 (Rev. 01/2020)
U.S. Department of the Interior
OMB Control No. 1018-0093
Expires ##/##/####
6. For EACH animal from which samples are to be shipped, provide the following (You may use the attached
corresponding inventory sheet): Please do NOT include Quarantine, Immunization or Health records unless
they document transfer of ownership. (See sample inventory page provided.)
a.
Scientific name (genus, species, and, if applicable, subspecies);
b.
Common name;
c.
Animal's microchip, tag, band, or other identification number or House name;
d.
Sex, if known;
e.
Birth/hatch date or age class;
f.
Source of specimen (Wild or Captive-Born);
g.
If animal or specimen was previously imported into the United States, foreign CITES export permit number and
issuance date associated with that import;
h.
Type of sample (e.g., blood samples, cell cultures, tissue samples); and
i.
Quantity of samples & how packaged (e.g., 10 1-ml flasks, paraffin blocks, slides).
NOTE: Specific quantities are not required if establishing a master file.
7. What is the purpose of the export?
____ Commercial
____ Scientific
____ Other (specify: _____________________________)
8. Where is/are the specimen(s) currently located?
Name:
Address:
City, State/Province:
County, Postal Code:
9. For wildlife previously imported into the United States from another country, provide:
a.
All copies of canceled CITES export or re-export documents issued by the appropriate CITES office in the
country from which the wildlife was exported,
b.
All copies of cleared wildlife Declaration for Import (Form 3-177),
c.
Copies of Inventory sheets that accompanied the original shipment showing original tattoo #’s, and
d.
If you did not make the original import, provide copies of the importer's documents outlined above and the
invoices or other documents that shows you acquired the wildlife from the original importer or history of
transactions (chain of ownership).
10. For samples collected from animals born in the wild in the United States, provide:
a.
Have the specimens been collected? If not, when will they be collected?
b.
Specific location of where, when and by whom (name and address) the animal/sample was removed from
the wild,
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FWS Form 3-200-29 (Rev. 01/2020)
U.S. Department of the Interior
OMB Control No. 1018-0093
Expires ##/##/####
c.
A description of the method(s) of collection, including previous results using this methodology (e.g. mortality
rate, adverse impacts). If mortality occurred, how was the methodology modified to reduce future
incidences of injury or death? If the animal was removed from the wild and held for an extended period in
captivity, describe the length of time the animal was held in captivity and, if still in captivity, the location and
future disposition of the animal,
d.
The qualifications of the individuals collecting the animal or samples,
e.
A copy of any applicable local, Tribal, State, or Federal government authorization approving the activity, and
f.
Documentation that the applicant legally acquired the animals/samples.
11. For samples collected from animals born in captivity within the United States:
a.
Have the specimens been collected? If not, when will they be collected?
b.
A description of the method(s) of collection, including previous results using this methodology (e.g. mortality
rate, adverse impacts). If mortality occurred, how was the methodology modified to reduce future
incidences of injury or death?
c.
The qualifications of the individuals collecting the animal or samples,
d.
A copy of any applicable local, Tribal, State, or Federal government authorization approving the activity.
12. If you are the breeder, please provide a dated statement that the animal was bred and born at your facility. This
statement must include:
a.
Name and address of the breeding facility;
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FWS Form 3-200-29 (Rev. 01/2020)
U.S. Department of the Interior
OMB Control No. 1018-0093
Expires ##/##/####
b.
Birth/hatch date, band/tag number, and sex of each specimen; and
c.
Signature of the attending veterinarian or animal caretaker in charge of the breeding operation.
13. If you are NOT the breeder of the animals, provide copies of documentation showing that the specimens were
legally acquired, such as documentation that demonstrates the history of transactions (e.g., chain of custody) and
a dated signed statement from the breeder or breeder's record that includes:
a.
Complete name and address of the breeder's facility;
b.
Scientific name; birth/hatch date, sex, and, if applicable, band/tag number or other identifier of each
specimen bred;
c.
Statement that the animal was bred and born at the breeder’s facility;
d.
Location (name of holder, city, State, zip code) of parental stock;
e.
Whether the parental stock was captive-born or wild-caught; and
f.
Signature of the attending veterinarian, or animal caretaker in charge of the colony
14. For marine mammals samples, provide a copy of your FWS or NOAA Fisheries permit or authorization.
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 3-200-29 (Rev. 01/2020)
U.S. Department of the Interior
OMB Control No. 1018-0093
Expires ##/##/####
Please do not submit handwritten inventories with your application. You may re-create this form as long as it contains all the necessary information.
Scientific Name
(Genus species)
Original
Animal #
Ex: Macaca fascicularis
Rx7272-09
Export/Re-export of Wildlife Samples (CITES)
Inventory Page
Current
Animal #
Gender
Birth Date
mm/dd/yyyy
CITES export
Permit #
F
05/06/1992
VN010-1998
*For master files, shipment totals for vials/flasks/slides and sample quantity may be left blank.
Enter shipment totals
for animals, sample
quantity, and
vials/flasks/slides, etc.*
Type of sample
Quantity of samples
& how packaged
20 1ml vials containing 0.5 ml liver cell
samples each
Animals=
Vials/slides=
Sample Quantity=
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FWS Form 3-200-29 (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 1 hour 45 minutes (original submission electronic) to 2 hours 30 minutes (original submission - paper-based) and 1 hour 30 minutes (amended submission electronic) and 1 hour 45 minutes (amended submission - paper-based), 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.
Page 8 of 8
| File Type | application/pdf |
| File Title | NPS Form 10-29 |
| Author | dhaas |
| File Modified | 2020-03-09 |
| File Created | 2020-01-24 |