Form 3-200-39A Annual Report - Certificate of Scientific Exchange (COSE

FWS Form 3-200-39A (Rev. 02/2023)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires XX/XX/XXXX

CERTIFICATE OF SCIENTIFIC EXCHANGE (COSE) SPECIAL REPORTING CONDITIONS
PERMIT #: ______________________(ex. 20US123456/9)
PERMITEE:_________________________________________
Reporting Requirements: Annually, permittee must provide a report to the Division of Management Authority, Branch of
Permits, MS: IA; 5275 Leesburg Pike; Falls Church, VA 22041-3803 or e-mail report [email protected]. This
report must describe all exchanges of specimens that occurred in the preceding calendar year and made under the registered
scientific institution system under the COSE [CITES Resolution Conf. 11.15 (Rev. CoP18)]. A suggested format is described
below. Non-activity must also be reported. If reports are not received annually, the CITES registration is subject to revocation.
Outgoing Specimen Report
Date Sent

Description
of specimen

Accession
or Record
no.

Scientific
name and
common
name

Receivin
g
institutio
n,
Country

COSE Code No.

Accession
or Record
no.

Scientific
name and
common
name

Originatin
g
institution
, Country

COSE Code No.

Incoming Specimen Report
Date Received

Description
of specimen

In addition, permittee must maintain complete and accurate records of any specimens imported or exported under
this Certificate (50 CFR 13.46). The records must be kept current and should include the name, address, and
COSE number of the institution sending or receiving specimen(s), a description of the specimen(s) exchanged,
and the date the exchange occurred. The records must be maintained for five years from the date of expiration of
the Certificate. The permittee must make the records available to US Fish and Wildlife Service employees for
inspection upon request.
E-MAIL YOUR REPORT TO: [email protected] (Reference “COSE Annual Report for PRT #
on the Subject Line) or mail to address on the Permit.

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FWS Form 3-200-39A (Rev. 02/2023)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires XX/XX/XXXX

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 Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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 which
affect protected species. This helps 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
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) in order provide the U.S. Fish and
Wildlife Service the information necessary, under the applicable laws governing the requested activity, for which a permit is
requested. 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 applicable 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.
1018-0093.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 24 minutes (electronically) to 30 minutes (paperbased), 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: 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 permits from Management Authority should be sent to [email protected].

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