3-2300 Incumbent Application Form

FWS Form 3-2300 (Rev. 05/2018)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0075
Expires ##/##/2022

INCUMBENT APPLICATION FORM
Federal Subsistence Regional Advisory Council Membership

APPLICANT’S FULL NAME:
MR./MRS.:_______________________________________________________
FIRST
Full mailing address:

MIDDLE

_

LAST
Contact Information:
Home: (907)
Work: (907)
Fax: (907)
E-mail:
Birthdate:

Where is your (or your nominee’s) primary place of residence? (Please note that members must
reside in the region they represent.)
PLEASE ANSWER THE FOLLOWING QUESTIONS (ATTACH ADDITIONAL PAGES IF NEEDED):
1) Describe any updates or changes to answers you provided in your last fully-completed
Application/Nominations Form (Form 3-2321).

2) Why do you wish to continue serving on the Regional Advisory Council? What would be your
goals for another term?

3) Regional Council membership should reflect representation of subsistence and commercial/
sport interests. Regional Council seats are designated for either subsistence use or commercial/
sport use representatives. You must choose one or the other.
_____ a. subsistence _____ b. commercial/sport

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FWS Form 3-2300 (Rev. 05/2018)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0075
Expires ##/##/2022

Reference Contacts: Please include three references and their contact information. Please provide the
most current phone numbers available. If you wish, you may also submit letter(s) of recommendation.

Name:
Organization:
Address:
Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Name:
Organization:
Address:

Name:
Organization:
Address:

I certify, to the best of my knowledge, that all statements are correct and complete.
Signature

Date

Please note: All applications must be signed in ink. No application or nomination will
be considered complete without a signature.

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FWS Form 3-2300 (Rev. 05/2018)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0075
Expires ##/##/2022

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the Alaska National Interest Lands Conservation Act; 36 CFR
242 and 50 CFR 100.
Purpose: The applicant’s information will be used to evaluate their qualifications and experience for the potential
selection to serve as a member on one of the Federal Subsistence Regional Advisory Councils.
Routine Uses: The Federal Subsistence Board will use the provided information to make recommendations to the
Secretaries of Interior and Agriculture for the appointment of members to the Federal Subsistence Regional Advisory
Councils. More information about routine uses can be found in the System of Records Notice, Permits System,
FWS-21.
Disclosure: Providing the information is voluntary, but required to obtain or retain a benefit.
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 make recommendations to the Secretaries of the Interior and Agriculture for appointment of
members to the Federal Subsistence Regional Advisory Councils. It is our policy not to use your name for any other
purpose. Your response is voluntary, but is required to obtain or retain a benefit. 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. 1018-0075.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 30 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
Collection Clearance Officer, Division of Policy, Performance, and Management Programs, Fish and Wildlife Service,
Mail Stop BPHC, 5275 Leesburg Pike, 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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