3-2358 Fishing-Shrimping-Crabbing-Frogging Application/Permit -

Hunting and Fishing Application Forms and Activity Reports for National Wildlife Refuges and National Fish Hatcheries (50 CFR parts 32 and 71)

3-2358 Fish Shrimp Crab Frog Permit App 04282022 (508)

OMB: 1018-0140

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FWS Form 3-2358 (Rev. 04/2022) OMB Control. No. 1018-0140

U.S. Fish and Wildlife Service Expiration Date ##/##/20##

F ISHING – SHRIMPING – CRABBING – FROGGING

APPLICATION/PERMIT

National Wildlife Refuge System


[NAME OF REFUGE]

[Insert address, phone number, email,

website, and/or other pertinent info]


PERMIT (Refuge Use Only)

Permit Number: ___________________ Valid for Season: ___________________________________________


Follow instructions in the refuge fishing publications; not all fields may be required. Read and comply with all refuge regulations, including application deadlines. [Refuge to insert submission instructions and deadline information here.]


Permit Application State Fishing License No.

Date of Application            


Permit Type (Check all that Apply) Location

Fishing Shrimping Crabbing Frogging Other (Describe):            


Contact Informatoin

Full Legal Name

     

Mailing Address City State Zip Code

                       

Daytime Phone (Incl. Area Code) Cell Phone (Incl. Area Code) Email Address

                 


Fishing Locations/Special Events

[Refuges may customize this section with details about fishing locations or special events]



I have read and understand the refuge hunt regulations and agree to abide by the regulations governing fishing activities on the refuge. [Refuges to insert applicable CFR citation for regulations]




_______________________________________

Applicant Signature


----------------------------------------------------------------------------------------------------------------------------------------------------------------

For USFWS Use Only

Date Received: ____________________


Payment Exempt/No Fee Payment Required Payment Amount: ________________


Payment Type: Personal Check Cashier’s Check Money Order Other:      


Notes: __________________________________________________________________________________________







NOTICES


All information you provide will be considered in reviewing this application. False, fictitious, or fraudulent statements or representations made in the application may be grounds for revocation of the permit and may be punishable by fine or imprisonment (18 U.S.C. 1001).

Privacy Act Statement


Authority:  The information requested is authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) as amended and the Refuge Recreation Act (16 U.S.C. 460k – 460k-4, 640K-3, & 664).  

Purpose:  The collection of personal information is to verify that an individual is eligible to receive a permit to conduct monitored activity on areas within the National Wildlife Refuge System, national fish hatcheries, and other conservation areas administered by the Secretary of the Interior for fish and wildlife purposes.  

Routine Uses:  The individual’s information will be used to verify permit status, provide permittees with permit-related information, and monitor activities conducted under a permit. This information may be shared in accordance with the Privacy Act of 1974 and the routine uses listed in the System of Records Notices: FWS-5 National Wildlife Refuge Special Use Permits; FWS-21 Permits System; FWS-10 National Fish Hatchery Special Use Permits.  

Disclosure:  Providing the information is voluntary; however, as a requirement for maintaining a Federal permit under the National Wildlife Refuge System Administration Act, failure to disclose the requested information may be sufficient cause for revocation of the permit.

Paperwork Reduction Act Statement


We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) to provide the refuge managers the information needed to decide whether or not to allow the requested use, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. The information that you provide is voluntary; however, submission of the requested information is required to evaluate the qualifications, determine eligibility, and document permit applicants. Failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. We may not conduct or sponsor and you are 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 OMB Control No. 1018-0140.


Estimated Burden Statement


Public reporting for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed application to this address.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBaucum, Madonna L
File Modified0000-00-00
File Created2022-09-26

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