NSF 1078 Antarctic Conservation Act Application and Permit Form

FORM APPROVED
OMB NO. 3145-0034

NATIONAL SCIENCE FOUNDATION
ARLINGTON, VIRGINIA 22230

ANTARCTIC CONSERVATION ACT
APPLICATION AND PERMIT FORM

1. TYPE OF PERMIT REQUESTED
… TAKE
… HARMFUL INTERFERENCE
… ENTER ANTARCTIC SPECIALLY PROTECTED AREA
… INTRODUCE NON-INDIGENOUS SPECIES INTO ANTARCTICA

PROPOSAL NO.

… IMPORT INTO USA—PORT OF ENTRY
__________________________________________
… EXPORT FROM USA

2. NAME, ADDRESS, PHONE/FAX NO. AND E-MAIL ADDRESS OF APPLICANT (IF A CORPORATION, FIRM, PARTNERSHIP,
INSTITUTION, OR AGENCY, EITHER PUBLIC OR PRIVATE, COMPLETE BLOCK 3).

3. NAME AND ADDRESS OF PRESIDENT OR PRINCIPAL OFFICER

4. IF APPLICANT IS AN INDIVIDUAL, INCLUDE BUSINESS OR
INSTITUTIONAL AFFILIATION

5. NAME OF APPLICANT'S AGENTS (FIELD PARTY MEMBERS), IF ANY (USE
"TBA" IF NAMES UNKNOWN)

6. DESIRED EFFECTIVE DATES

7. LOCATION(S)—INCLUDE MANNER OF TAKING OR HARMFUL INTERFERENCE AND PROPOSED ACCESS TO THE LOCATION

8. SPECIMEN INFORMATION
SPECIES

NUMBER

AGE

SEX

SIZE

CONDITION

IMPORT TO
USA

ULTIMATE
DISPOSITION

CERTIFICATION
I certify that the information submitted in this application for a permit is complete and accurate to the best of my knowledge and belief. Any false statement will subject me to
the criminal penalties of 18 U.S.C. 1001.

SIGNATURE

DATE

FOR NSF USE ONLY
This application for a permit under the Antarctic Conservation Act, P.L. 95-541, as amended, and NSF regulations contained in Title 45 Part 670 of the Code of Federal
Regulations is approved subject to the following conditions:

THIS PERMIT EXPIRES ON: ________________________
(Date)
TYPED NAME AND TITLE AND SIGNATURE OF NSF AUTHORIZING OFFICIAL

NSF Form 1078

DATE

CONTINUE ON REVERSE SIDE

9. DESCRIPTION OF ACTIVITY FOR WHICH PERMIT IS NEEDED AND JUSTIFICATION FOR PROJECT. ALSO INCLUDE HERE
ADDITIONAL INFORMATION RELATING TO THE SPECIFIC ACTION FOR WHICH THE PERMIT IS BEING SOUGHT.

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS
The information requested in this application is solicited under the authority of the Antarctic Conservation Act (ACA), as amended, the National Science Foundation Act of
1950, as amended, and NSF regulations at 45 CFR Part 670. The information will be used in administration of the ACA, particularly to make a determination on eligibility for
an ACA permit. The information requested may be disclosed to other Federal agencies or a court, administrative, or adjudicative body involved in implementing or enforcing
the ACA; to Federal, state, or local agencies, or foreign governments, where necessary to obtain records in connection with an investigation, or to persons, including
witnesses, who may have information, documents, or knowledge relevant to an ACA investigation or enforcement proceeding; to other Federal agencies when relevant to a
decision by that agency on a security clearance, on the award of a contract or grant, on the issuance of a license or other benefit, or on a disciplinary or other administrative
action concerning its employee; to government contractors, experts, volunteers and researchers as necessary to complete assigned work; to a grantee institution or
contractor in connection with an investigation or enforcement proceeding where an ACA violation is alleged against it or one of its employees, researchers, or subcontractors;
and to another Federal agency, court or party in a court or Federal administrative proceeding if the government is a party. Se e Systems of Records, NSF-56, “Antarctic
Conservation Act Files,” 59 Federal Register 5784 (February 8, 1994). Submission of this information is voluntary. However, f ailure to provide full and complete information
necessary for an eligibility determination may reduce the possibility of receiving a permit.

Public reporting burden for this collection of information is estimated to average one half hour per response, including the time for reviewing instructions. Send comments
regarding this burden estimate and any other aspect of this collection of information, including suggestions to reduce this burden, to the NSF Reports Clearance Officer at c/o
the address directly below.

MAIL THIS
APPLICATION
TO:

OFFICE OF POLAR PROGRAMS (PERMIT OFFICE)
NATIONAL SCIENCE FOUNDATION, ROOM 755
ARLINGTON, VIRGINIA 22230