Form 3-200-78 Federal Fish and Wildlife Permit Application Form - Nati

Form 3-200-78 (Rev. 07/2019)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires 04/30/2021

Native American Tribal Eagle Aviary
(Bald and Golden Eagle Protection Act; 50 CFR 22.22)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

BEFORE FILLING OUT THIS FORM, please access
the Return Addresses (to obtain the email/postal
addresses where this form can be returned), review
the Frequently Asked Questions and Instructions.
Please retain the "NOTICES" page for your records.

SELECT YOUR TYPE OF REQUEST

New Application
Renewal
Amendment

If requesting a renewal or amendment, provide permit #:
Name of Federally Recognized Tribe:

A.

1.a. Last name

.
Complete
for the Tribal Leader (e.g., Governor or Chief) of your Federally Recognized Tribe

2. Title (Governor or Chief, etc.)

B.

1.c. Middle name or initial

1.b
1. First name

3.a. E-mail address

1.d. Suffix

3.d. Alternate Telephone Number

3.b. Telephone number

Complete for the Primary Contact Person
(The US Fish and Wildlife Service, Office of Law Enforcement will communicate with this tribal member for
questions related to the official transfer of possession of eagle remains.)

4.a. Primary Contact Last name.

4.b. Primary Contact First Name

5. Primary Contact's Business Telephone Number

C.

6. Contact's Alternate Telephone Number

7. Business e-mail address

Tribal Office Information

8. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
9. City

10. State

11. Zip code/Postal code:

13. Country

12. County/Province

14. Mailing Address (include if different than physical address; include name of contact person if applicable)
15. City

D.

16. State

17. Zip code/Postal code:

18. County/Province

19. Country

Tribal Leader Identified in Box A. Must Read and Sign

1. Processing fee: This application has no processing fee.
2. 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.

Signature of the Principal Officer (No stamped signatures. Electronic signatures accepted.)

Date of signature (mm/dd/yyyy)

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Form 3-200-78 (Rev. 07/2019)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires 04/30/2021

Native American Tribal Eagle Aviary
(Bald and Golden Eagle Protection Act; 50 CFR 22.22)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

Note: A Federal Tribal Eagle Aviary permit is required to possess non-releasable live eagles for Indian religious use. You must be
a federally recognized tribal entity under the Federally Recognized Tribal List Act of 1994, 25 U.S.C. 479a-1, 108 Stat. 4791 (1994)
to apply (complete section B on page 1). The Tribal Eagle Aviary facility must be under the control of the tribal governing body.
This application requires certification that the requesting individual (Principal Officer) is an enrolled member of a Federally
Recognized Tribe. Complete the Certificate of Enrollment form below for the Principal Officer indicated in Section B above. The
Primary Caretaker must be at least 18 years old and demonstrate sufficient experience handling and caring for eagles. At least
300 hours working with eagles is recommended. You must be at least 18 years old to apply for a migratory bird permit. Please read
“Frequently Asked Questions” and the pertinent regulations before you sign and submit your application. Your signature on the
application affirms that you are requesting eagle(s) for religious purposes.
Please provide the information requested below. If additional information needs to be provided that does not fit in the designated
spaces, add additional sheets to your application submission. You may use as many additional sheets as needed. Please number
pages accordingly using the page number box provided at the bottom of the sheet, and the corresponding question number.
You should be as thorough and specific as possible in your responses. Incomplete applications will be returned.
As the permittee, you are legally responsible for ensuring that your subpermittees, staff, and volunteers adhere to the terms of your
permit.

Section E.
Questions
1)

Attachments - In additions to this form, you should also attach the following to complete your application:

a) Attach photographs and diagrams of your permanent facilities/enclosures for housing migratory birds (both
indoor and outdoor). Diagrams must include dimensions (length, width, and height) and a description of interior
and exterior construction materials, such as flooring and netting materials. Indicate the species or type of
species that will be housed in each. Also provide a description of the interior and exterior construction and
housing materials, such as flooring, netting, perching, and watering materials.
b) Provide a written recommendation from another Federal permittee with eagle handling experience familiar with
the Primary Caretaker’s eagle experience.
2) Any permit issued as a result of this application is not valid unless you also have any required State or tribal permits or
approvals associated with the activity. Have you obtained all required State or tribal permits or approvals to conduct this
activity?
Yes, Have Attached
None Required
Have Applied, Will Provide Upon Request

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Form 3-200-78 (Rev. 07/2019)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires 04/30/2021

3) Please provide the following information for the Primary Caretaker:
a) For each live eagle you propose to use, describe in detail your experience handling and caring for those
species.

b) Provide the name, address, and telephone number of the facility or facilities where your experience was obtained.

4) Anyone who will be assisting you with the permitted activities or acting as your agent must either have their own Federal
migratory bird permit for the activity or be identified by you, in writing, as a subpermittee under your permit. They may also
require a State permit. Subpermittees must be at least 18 years old. As the primary permittee, you will be responsible for
ensuring that your subpermittees are properly trained and adhere to the terms of your permit. Provide the name of anyone who
will conduct permitted activities in your absence. For each individual, list the type of activity, location, and duration (if less than
permit tenure) they will be conducting and their experience in conducting those activities. The physical location(s) of activities
conducted must include any activities conducted by subpermittees.

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Form 3-200-78 (Rev. 07/2019)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires 04/30/2021

5) Veterinarian: Provide the name, address, telephone number and email address of the veterinarian(s) you will be using
for routine care and/or emergency medical care. Describe the veterinarian’s experience with avian species, including
raptors.

6)

Describe your permanent facilities for eagles.
a) Describe the location where the eagle(s) will be housed, including the physical address and/or GPS coordinates
where the aviary is located.

b) Provide a list of the eagle(s) you intend to house in each enclosure, including the species, number of eagles, and
flight status (flighted, non-flighted) of each eagle

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Form 3-200-78 (Rev. 07/2019)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires 04/30/2021

7) For each live eagle you intend to acquire under this permit
a) Describe the diet you will administer and indicate food source.

b)

Describe the types of daily enrichment you will provide for each eagle.

8) All eagles held under this permit will be used for Indian Religious Purposes (per 50 CFR 22.22).
Yes
No
9) You must retain records legibly written or reproducible in English relating to the activities conducted
under your permit for at least 5 years after the date of expiration of your permit. Is the physical address you
provided in Section C on page 1 of this application the address where your records will be kept?
Yes

No. If “no,” provide
the physical address

10) I acknowledge that I have read the form Instructions and Frequently Asked Questions, and have accessed the page with the
Return Addresses to obtain the address where I should return this form. I have also filled out all fields and questions in this
application. Check this box to acknowledge:

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Form 3-200-78 (Rev. 07/2019)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires 04/30/2021

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 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 that affect protected
species. The information the individual provides helps the 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
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary to
monitor take and disposition of migratory birds, under the applicable laws governing the requested activity, for which a permit is
requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. 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 above 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. 1018-0022.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 4 hours for the application and 1 hour for recordkeeping,
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.
FREEDOM OF INFORMATION ACT
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that
you identify any information that should be considered privileged and confidential business information to allow the Service to meet its
responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter or
page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

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