Export Certification Application

See instruction page(s) for information on how to make your application complete and help avoid unnecessary delays.

Type of Request

New Application _________

Amendment _________

(If requesting an amendment, provide Export Certification #)

1. Complete if applying as an individual.

1.a. Last Name 1.b. First Name 1.c. Middle Name or initial 1.d. Suffix

2. DOB (xx/xx/xxxx) 3.a Telephone Number 3.b Alternate Number 3.d. Email Address

2. Complete if applying as business, corporation, public agency, Tribe, NHO or institution.

1.a. Name 1.b. Doing business as (d/b/a)

2.Federal TAX ID No. 3. Description of entity – business, agency, Tribe, NHO, etc.

4.a. Principal Officer Last Name 4.b. Principal Officer First Name 4.c. Principal Officer Middle Name 4.d. Suffix

5. Principal Officer Title 6. Primary Contact Name

7.a. Business Telephone Number 7.b Business Fax 7.c. Email Address

3. All Applicants Complete

1.a. Physical Address 1.b. City 1.c. State 1.d. Zip Code 1.e Country

2.a. Mailing Address (if different) 2.b. City 2.c. State 2.d. Zip Code 2.e Country

4. All Applicants Complete

1. A nonrefundable processing fee is required to process this permit application, please attach check or money order payable to the U.S. Department of the Interior. Federal, Tribal, State, and local government agencies and Native Hawaiian organizations are exempt from the processing fee.

2. Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 25, Part 1194 of the Code of Federal Regulations, and I certify that the information submitted in this application for a certification is complete and accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to civil penalties under 18 U.S.C. § 1001, and further, a violation of the STOP ACT may subject me to criminal penalties under 18 U.S.C. § 1170, 16 U.S.C. § 470ee, and 25 U.S.C. § 3073.

3, I further certify, to the best of my knowledge and belief, I am not attempting to export an Item Prohibited from Exportation.

__________________________________ __________________________

Signature of Applicant/Principal Officer Date of Signature

Section E. Notice (initial as requested to confirm that you understand that paragraph)

1. No person may export, attempt to export, or otherwise transport from the United States any Item Requiring Export Certification, as that term is defined in 25 C.F.R. § 1194.2, without first having obtained an Export Certification. Any person who wants to export an item that may be an Item Requiring Export Certification must first apply to the Secretary for an Export Certification of that item before transporting or shipping the item to any foreign country. _______________ Initials

2. Each item to be transported requires a separate application and each application will be processed separately. The Secretary will process the application using the procedure in section 25 C.F.R. § 1194.8. You are responsible for reviewing and understanding the applicable regulations before you apply for and accept and Export Certification. Please read the pertinent regulations before you sign and submit your application.

3. Please provide the information requested below. Additional information may be added by inserting additional sheets to your application submission. You may use as many additional sheets as needed. Please number pages accordingly, and include the corresponding question number.

4. You should be as thorough and specific as possible in your responses. Incomplete applications will be returned.

5. As the applicant, you are legally responsible for ensuring that your employees, agents, and any persons acting pursuant to your Export Certification adhere to its terms. _______________ Initials

Section F. Questions

1. Indicate what Item Requiring Export Certification (“Item”) you are seeking to export and include the following information:

1. Description and pictures (if culturally appropriate) of the Item;

2. Complete and accurate statement of the provenance of the Item;

3. Disclosure of the presence of any potentially hazardous substances used to treat the Item;

4. Evidence showing cultural affiliation under 43 C.F.R. § 10.3;

5. Substantial evidence showing consultation with possibly culturally affiliated Indian Tribes or Native Hawaiian organizations; and

6. The purpose and timeframe for the proposed exportation of the Item.

2. For an Item that is an Archaeological Resource (25 C.F.R. § 1194.2):

   1. Attach permit under Section 4 of the Archaeological Resources Protection Act, 16 U.S.C. § 470cc authorizing export of the Item; or

   2. Submit evidence that a permit is not required.

3. For an Item that is a Native American cultural item (25 C.F.R. § 1194.2):

   1. Attach a Disposition Statement (43 C.F.R. §§ 10.7(b) or (c)(5)) or a Repatriation Statement (43 C.F.R. § 10.9(g)); or

   2. Submit evidence that neither a Disposition Statement or Repatriation Statement is necessary, with written confirmation from the Indian Tribe or Native Hawaiian organization with authority to alienate the Item Requiring Export Certification that:

      1. The exporter has a right of possession of the Item; or

      2. The Indian Tribe or Native Hawaiian organization has relinquished title or control of the in accordance with section 3 of NAGPRA.

4. For an Item that was excavated or removed, submit evidence of the ownership of the land from which the Item was removed at the time it was removed and at the time of the application.

5. All documentation supporting the application must be submitted in the format required for upload into the Export Certification Database.

6. All applications must include the following information:

   1. Name and address of the person or organization in the foreign country to which you are exporting.

   2. If you reside or are located outside of the United States: provide the name of a contact, address, and telephone number where you can be reached in the United States.

   3. If conducting commercial activities, provide the name and address of your registered agent located in the United States.

   4. Provide the intended U.S. port of exit.

END

Paperwork Reduction Act Statement: In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.), the U.S. Department of the Interior collects information necessary to compute payments due units of general local government under the Payment in Lieu of Taxes Act (31 U.S.C. 6901-6907), and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information requested in this form is required to obtain or retain a benefit. According to the Paperwork Reduction Act, 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. 1076-NEW.

Estimated Burden Statement: We estimate the public reporting burden for this information collection to be 18 hours for individuals. We estimate the recordkeeping burden for this information collection to be 2 hours for individuals. These burden estimates include time for reviewing instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the information. Send comments regarding the accuracy of this burden estimate and any suggestions for reducing the burden to Information Collection Clearance Officer, Indian Affairs, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104, or via email at [email protected].

PRIVACY ACT STATEMENT: [TBD].

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