PIPA Pelagic Squid Jig

OMB Control No: 0648-0490
Expires: 03/31/2024

U.S. DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
NATIONAL MARINE FISHERIES SERVICE

Pacific Islands Regional Office - SFD Permits
1845 Wasp Blvd., Bldg 176
Honolulu, Hawaii 96818
(808) 725-5190 ∙ [email protected]

PACIFIC ISLANDS PERMIT APPLICATION

PELAGIC SQUID JIG

Please print legibly. Items marked with an asterisk (*) are required. Note required documents and instructions on page 2. Do not mail application or
check. Send application via secure email and pay non-refundable application processing fee of $71 online per instructions on page 2.
*VESSEL NAME: _____________________________________________________________ *VESSEL OFFICIAL NO: _____________________

USCG or State registration number

*VESSEL LENGTH: ________________ (feet) Permit is required for vessels >= 50 ft LOA)

*RADIO CALL SIGN: _______________________

*VESSEL OWNER: _____________________________________________________________________
*PERMIT HOLDER: _____________________________________________________________________

__________________________

*Taxpayer ID Number (EIN or SSN)

First, Middle, & Last Name or Business Name to be designated Permit Holder

*DATE OF BIRTH (Individual) OR INCORPORATION (Business): _______________________________ (MM/DD/YYYY)
*CONTACT PERSON: ______________________________________________________________ TITLE: _____________________________
First, Middle, & Last Name, if not same as permit holder

Corporate officer, business owner, partner

*BUSINESS MAILING ADDRESS: ______________________________________________ ___________________
Street/PO Box

City

____

_____________

State

ZIP

*BUSINESS PHONE: _________________________ CELL PHONE: _________________________ (include area codes)
*EMAIL: __________________________________________________________
Under penalty of perjury, I hereby declare that I, the undersigned, am the applicant, or authorized to complete and certify this application on behalf of the
applicant, and the information contained herein is true, correct, and complete to the best of my knowledge.

*APPLICANT: ___________________________________ ________________________________________
Printed Name of Person Submitting Application

Signature

*DATE: ____________________
(MM/DD/YYYY)

*APPLICANT TITLE: ___ Vessel owner, ___ Permit holder, ___ Corporate officer or partner, ___ Designated agent**, or ___ Other_____________
(Check only one)
*Application is for ___ a new permit or ___ a renewal? If renewal, previous permit number? ________________________
An application that is lacking required information, vessel registration or documentation, or payment will be considered incomplete. An incomplete
application will be abandoned if it is not completed within 30 days after notification of deficiency (50 CFR 665.13(c)(2)). You must inform PIRO within
15 days of any change of information on the application form (50 CFR 665.13(d)). It is prohibited to file false information on any application for a
fishing permit (50 CFR 665.15(b)).
Revised 10/18/2021

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INSTRUCTIONS
Please print all information legibly. Illegible writing may cause delays or errors in permit processing. All items marked with an asterisk (*) on the form
must be completed.
Vessel Name: Write the vessel name that is marked on the vessel and/or listed on the US Coast Guard (USCG) certificate of documentation or
state/territory vessel registration form. If vessel is undocumented and has no name, please write N/A or None.
Vessel Official No.: Write the vessel’s USCG documented number or state/territory undocumented vessel registration number.
Vessel Length: Write the length overall as documented by the USCG or state/territory registration.
Radio Call Sign: Write the call sign registered with the FCC if available.
Vessel Owner: Write the name of the documented or registered vessel owner.
Permit Holder: Write the name of the person or business to whom the permit will be issued. If it will be the same as the Vessel Owner, write Same.
Taxpayer ID Number: For individuals, this is your Social Security Number (SSN); for businesses, this is the Employer Identification Number (EIN).
Date of Birth or Incorporation: Write the date of birth for individuals, or date of incorporation for businesses.
Contact Person, Business Address, Business Phone and other contact information: Write the contact person name, contact person title,
permit holder’s mailing address, and permit holder’s telephone number. These will be the address and phone number of record. Provide the cell
phone number and email.
Applicant and Date: The new or renewing permit holder (if individual) or an officer or member of the business or corporation submitting the
application must print their name and write their signature. Write the full date (MM/DD/YYYY) when the application is signed.
Applicant Title: Check the role of the applicant. If the applicant is a designated agent, then a written, signed, and dated letter of authorization from
the permit holder naming the applicant as a designated agent is required.
New or Renewal?: Check one. If this is a renewal, write the previous permit number associated with this vessel and permit holder.
Required Documents. You must submit the following with the application form:
1) A copy of the vessel's current U.S. Coast Guard Certificate of Documentation (documented vessel) or registration certificate from a state/territorial
agency (undocumented vessel) showing the current vessel owner,
2) **If the Applicant is not the vessel owner, you must provide a signed letter from the permit holder authorizing the applicant to act as an agent for
the permit holder.
Send the application via secure email and pay fee online following the instructions at https://www.fisheries.noaa.gov/pacific-islands/commercialfishing/apply-pacific-islands-fishing-permit.
An application that is lacking required information, vessel registration or documentation, or payment will be considered incomplete. An incomplete
application will be abandoned if it is not completed within 30 days after notification of deficiency (50 CFR 665.13(c)(2)), and you must inform PIRO
within 15 days of any change of information on the application form (50 CFR 665.13(d)). It is prohibited to file false information on any application for
a fishing permit (50 CFR 665.15(b)).

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PRIVACY ACT STATEMENT
Authority: The collection of this information is authorized under the Magnuson-Stevens Fishery Conservation and Management Act (16 U.S.C 1801
et seq.), the Western and Central Pacific Fisheries Convention Implementation Act (WCPFCIA; 16 U.S.C. 6901 et seq.), the Marine Mammal
Protection Act (16 U.S.C. 1362 et seq.), and the Endangered Species Act (16 U.S.C. 1531 et seq.). The authority for the mandatory collection of the
Tax Identification Number (TIN) is 31 U.S.C. 7701.
Purpose: In order to manage U.S. fisheries, the NOAA National Marine Fisheries Service (NMFS) requires the use of permits or registrations by
participants in the United States. Information on NOAA Fisheries permit applicants and renewing permit holders includes vessel owner contact
information, date of birth, Tax Identification Number, and vessel descriptive information. Permit holder information may be used as sampling frames
for surveys.
Routine Uses: The Department will use this information to determine permit eligibility and to identify fishery participants. Disclosure of this
information is permitted within NMFS offices under the Privacy Act of 1974 (5 U.S.C. 552a) to coordinate monitoring and management of fisheries
and protected resources, as well as with the applicable State or Regional Marine Fisheries Commissions and International Organizations. Disclosure
of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/NOAA19, Permits and Registrations for the United States Federally Regulated Fisheries.
Disclosure: Furnishing this information is voluntary; however, failure to provide complete and accurate information will prevent the determination of
eligibility for a permit.
PAPERWORK REDUCTION ACT INFORMATION
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to
comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a
currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0648-0490. Without this approval, we
could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 30 minutes per permit
application and 2 hours per permit denial appeal, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are voluntary.
Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to
the NMFS Pacific Islands Regional Office at [email protected]