Form 3-200-90 Special Double Crested Cormorant Permit

FWS Form 3-200-90 (Rev. 02/2023)
U.S. Department of the Interior

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

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM
Special Double-Crested Cormorant
(Migratory Bird Treaty Act; 50 CFR 21.123)
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 mail addresses where this form can be returned); and
read the Permit Information, Frequently Asked Questions, and form
Instructions. Please retain the "NOTICES" page for your records.

TYPE OF REQUEST
New Application
Renewal

NOTE: A Federal Special Double-Crested Cormorant permit is available only
to a State or Tribal fish and wildlife management agency responsible for
migratory bird management on lands and waters under their jurisdiction.
Anyone conducting activities under authority of this permit must be listed as a
subpermittee. Subpermittees must be at least 18 years old. Nonlethal
methods to resolve conflicts must be attempted before lethal take occurs.

Amendment
If requesting a renewal or amendment, please
provide the permit #: _____________________

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details.
See instructions on last page for information on how to make your application complete and help avoid unnecessary delays.

A. Complete if applying as an individual
1.a. Last name

2. Date of birth (mm/dd/yyyy)

3.a. Telephone number

1.b. First name

1.c. Middle name or initial

3.b. Alternate telephone number

3.d. E-mail address

1.d. Suffix

B. Complete if applying on behalf of a State agency or Tribe
1.a. Name of Agency or Tribe

4.a. Principal Officer Last Name

4.b. Principal Officer First Name

5. Principal Officer Title

4.c. Principal Officer Middle Name/Initial 4.d. Suffix

6. Primary Contact Name

7.a. Business Telephone Number 7.b. Alternate Telephone Number 7.c. Business Fax Number

7.d. Business E-mail Address

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

2.c. State

2.d. Zip code/Postal code

2.e. County/Province

2.f. Country

D. All applicants MUST complete
1. Processing fees – none required. Tribal and State agencies, and those acting on behalf of such agencies, are exempt from the processing fee (50
CFR 13.11(d)(3)(i).
2. Do you currently have or have you ever had any Federal Fish and Wildlife permits?
Yes

No

If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: ___________________

3. 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 applicant/Principal Officer (No stamped signatures. Electronic signatures accepted.)

Date of signature (mm/dd/yyyy)

Please continue to next page
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FWS Form 3-200-90 (Rev. 02/2023)
U.S. Department of the Interior

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

SECTION E
Please provide the information requested below. We may request additional information as appropriate to the activities you are
requesting (50 CFR 13.21(d)). You should be as thorough and specific as possible in your responses. Incomplete applications
will be returned. If additional space is required, 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.
FOR RENEWAL APPLICATIONS: Please all questions in Section E below in addition to filling out Sections A-D above. All information
must be provided, required reporting must be up to date (use report form 3-202-56), and processing fees paid, or the renewal will not be
processed.
1)

Describe the history of double-crested cormorant conflicts in your state or tribal lands. Include locations(s) that are historically areas
for conflict and, for each location, the type of conflict experienced (aquaculture/hatchery, human health and safety, property damage,
t/e species protection, and/or wild and stocked fish). As appropriate, include the size/description of the area affected, how long this
conflict has been occurring, what time of year the conflict occurs, and what time of year you will be conducting management activities,
visit https:// earthexplorer.usgs.gov/

2)

For each location(s), describe the non-lethal methods that you have used previously and/or plan on implementing, including (a) active
hazing (e.g. horns, pyrotechnics, propane cannons, etc.), (b) passive deterrents (e.g. netting, exclusion devices, nest deterrents, etc.),
(c) habitat management (e.g. vegetative barriers, grass management, prey management, etc.), and (d) practice changes (e.g. water
level management, fish release timing, etc.).

3)

Describe your proposed double-crested cormorant management activities, including the number of double-crested cormorants you
propose to take by life-stage (i.e. adults, active nests, etc.) and the method you propose to use (i.e. shooting, nest-destroy, egg-oiling,
etc.).

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FWS Form 3-200-90 (Rev. 10/2020)
U.S. Department of the Interior

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

4)

Describe your long-term plans to eliminate or significantly reduce the continued killing of double-crested cormorants or destruction of
eggs/nests.

5)

The name and telephone number of the individual in your agency who will be in charge of the double-crested cormorant management
activities authorized under your permit.

6)

Subpermittees: 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. 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 any subpermittees who will be conducting activities under your
permit. Include the name and contact information of any commercial company that may be contracted to conduct the work.

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FWS Form 3-200-90 (Rev. 02/2023)
U.S. Department of the Interior

7)

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

By requesting this permit, I acknowledge that, if a permit is issued, the State/Tribe will be responsible for the following:
(a) A record keeping system for tracking take that includes: the specific location (GPS coordinates in decimal degrees), the county,
a description of the non-lethal methods implemented and their general efficacy for resolving the conflict, the number of doublecrested cormorants and, if applicable, non-target species taken, the method of take, and the purpose of take relevant to the type
of conflict (aquaculture, health, t/e, property, stocked fish). Take data must be current, sufficient to ensure tracking within
authorized take limits and update at least every 30 days.
(b) Activities that fall outside the scope of this permit require a separate Depredation permit. Activities may not occur under both a
Depredation permit and this permit.
(c) An outreach plan for communicating with the public the activities occurring under this permit, including the implementation nonlethal methods.
(d) The Principal Officer is responsible for ensuring all subpermittees (employees and contractors) are fully informed and briefed
regarding the regulatory requirements and conditions of this permit.
(e) Anyone taking birds under this permit must be skilled in double-crested cormorant identification. Non-target take of any other
avian species must be reported to your permit office with your annual report including species, number, and description of events.

8) 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
Yes
No If “no,” provide the physical address:
address where your records will be kept?

9) I acknowledge that I have read the Permit Information, form Instructions , Frequently Asked Questions; and have accessed the
Return Addresses for information on 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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FWS Form 3-200-90 (Rev. 02/2023)
U.S. Department of the Interior

OMB Control No. 1018-0022
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 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 et seq.), 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 averages:
Original submission - paper-based: 16 hours
Amended submission - paper-based: 4 hours
Original submission - electronic: 14 hours
Amended submission - electronic: 3 hours
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. Questions regarding migratory bird permits should be
sent to the appropriate regional (contact information can be found at https://www.fws.gov/program/migratory-bird-permit/contact-us).
FREEDOM OF INFORMATION ACT STATEMENT
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 Freedom of Information Act (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 non- confidential summary and remaining documents may be made available to the public under FOIA [43
CFR 2.26 – 2.33].

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