Form 3-186a Federal Fish and Wildlife Permit Application Form - Migr

FWS Form 3-186a (Rev. 01/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM
Migratory Bird Acquisition and Disposition

OMB Control No. 1018-0022
Expires ##/##/####

(Migratory Bird Treaty Act, 50 CFR 21.29, 21.30)

U.S. Fish and Wildlife Service
Division of Migratory Bird Management

USFWS Use Only
Received in Regional Office on
_____/______/_____ Initials:

1

SPECIES:

USFWS Band Number:__________________________

Sex:  Male

 Female  Unknown

Age:  Nestling
2

BEFORE FILLING OUT THIS FORM, please access the Return Addresses
(to obtain the email/postal mail addresses where this form can be
returned), and read the form Instructions.

 Immature

 Adult

SENDER (person transferring bird)

Source:  Captive-bred  Wild Microchip Number: ________________
(if applicable)
Year of Hatch: _________

USFWS Permit No.: ______________________________________________

Name: _____________________________________________ Date of Transfer (or other action): ___________________
Address: ____________________________________________________________________________________________
City: _______________________________________________ State:

Zip:______________________

E-Mail Address: ______________________________________________________________________________________
Permit: State Falconry FWS Raptor Propagation FWS Rehabilitation (see instructions) Other:______________
Transfer:

 Gift

 Sale

 Loan

If Release or Loss:  Release

3

 Escape

RECIPIENT (person acquiring bird)

Theft

 Death -- Cause of Death:

USFWS Permit No.: _______________________________________

Name: _________________________________________________________ Date of Acquisition: ___________________
Address: _____________________________________________________________________________________________
City:

State:

Zip: _______________________

E-Mail Address:_______________________________________________________________________________________
Permit Type:

 State Falconry

Type of Acquisition:  Gift

4

 FWS Raptor Propagation

 Purchase

 Loan

 Other: _______________________________________

 Capture/Recapture (complete section 4)

CAPTURE OR RECAPTURE (bird taken from the wild; provide band number in Section 1)  Capture

 Recapture

For all species, County (or comparable subdivision) and State of trapping location: ____________________________________
If you captured a gyrfalcon, what color is it?
5

 Grey

 White

Unknown (Nestling)

RE-BANDING (to report the re-banding of a wild or captive-bred bird) REQUIRED: Old bands returned to Migratory Bird Permit Office
Old Number:

 Seamless Metal

New Number:
6

 Black

 Yellow Plastic  Black Plastic

 Yellow Plastic

 Black Plastic

 Microchip

 Microchip

CERTIFICATION. I certify that the information submitted above is true and correct to the best of my knowledge. I understand
that making a false statement may subject me to the criminal penalties of 18 U.S.C. 1001.
Print name: ____________________________________________ Phone Number (with area code): ___________________
Signature of Permittee/Principal Officer:

(No stamped signatures. Electronic signatures accepted.)

Date of Signature:
(mm/dd/yyyy) ______________
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FWS Form 3-186a (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0022
Expires ##/##/####

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the Migratory Bird Treaty Act (16 U.S.C. 703 et seq), and Parts 13 and 21 of
Title 50 of the Code of Federal Regulations.
Purpose: To collect the contact information of individuals that hold Federal Raptor Propagation permits, Special Purpose Game Bird
(SPGB) permits, Special Purpose Abatement (SPA) permits and State Falconry programs. The states use a FWS application to
maintain information about the falconers and their birds.
Routine Uses: The information will be used to monitor disposition of captive birds and the take of birds from the wild. More
information about the routine uses may be found in the Systems of Records Notice, FWS-21 Permits System.
Disclosure: Providing the requested information is voluntary. However, submission of the requested information is required to
maintain Federal permit under the MBTA. Failure to disclose the requested information may be sufficient cause for revocation of the
permit. If the information indicates a violation of a statute, regulation, rule, order or license, whether civil, criminal, or regulatory in
nature, the information may be transferred to the appropriate Federal, State, local or foreign agency charged with investigating or
prosecuting such violations.

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
used to monitor disposition of captive birds and the take of birds from the wild, 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 averages:
Original submission - paper-based: 10 minutes (reporting) and 5 minutes (recordkeeping)
Original submission - electronic: 8 minutes (reporting) and 4 minutes (recordkeeping)
These estimates include 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 (JAO/3W), 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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