Form 3-200-77 Federal Fish and Wildlife Permit Application Form - Nati

Form 3-200-77 (Rev. 02/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires 07/31/2023

Native American Take for Religious Purposes
(Bald and Golden Eagle Protection Act; 50 CFR 22.60)
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 form Frequently Asked Questions, Instructions.
and Additional Information. Please retain the
"NOTICES" page for your records.

SELECT YOUR TYPE OF REQUEST

New Application
Renewal
Amendment

If requesting and amendment or renewal, provide permit #:
Name of Federally Recognized Tribe:

A.

1.a. Last name

.
Complete
for the Tribal Leader (e.g. Governor or Chief) of your Federally Recognized Tribe

2. Title (Governor or Chief, etc.)

B.

1.c. Middle name or initial

1.b
1. First name

3.a. E-mail address

1.d. Suffix

3.d. Alternate Telephone Number

3.b. Telephone number

Complete for the Primary Contact Person
(The US Fish and Wildlife Service, Office of Law Enforcement will communicate with this tribal member for
questions related to the official transfer of possession of eagle remains.)

4.a. Primary Contact Last name.

4.b. Primary Contact First Name

5. Primary Contact's Business Telephone Number

C.

6. Contact's Alternate Telephone Number

7. Business e-mail address

Tribal Office Information

8. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
9. City

10. State

11. Zip code/Postal code:

12. County/Province

13. Country

14. Mailing Address (include if different than physical address; include name of contact person if applicable)
15. City

16. State

17. Zip code/Postal code:

18. County/Province

D.

Tribal Leader Identified in Box A. Must Read and Sign

19. Country

1. Processing fee: This application has no processing fee.
2. 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 the Principal Officer (No stamped signatures. Electronic signatures accepted.)

Date of signature (mm/dd/yyyy)

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Form 3-200-77 (Rev. 02/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires 07/31/2023

NATIVE AMERICAN EAGLE TAKE FOR RELIGIOUS PURPOSES
(Bald and Golden Eagle Protection Act; 50 CFR 22.60)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

NOTE: A Federal Native American Eagle Take permit is required in order to take Bald Eagles or Golden Eagles from the wild for
Native American religious purposes. This permit is intended only for Tribes conducting a demonstrable historic religious ceremony
that requires take of live eagles from the wild. The Tribe must be one that is recognized under the Federally Recognized Tribal List
Act of 1994, 25 U.S.C. 479a-1, 108 Stat. 4791 (1994). Your signature on this application affirms that you are requesting an eagle(s)
for religious purposes and that your answers to the questions below are true and accurate to the best of your knowledge and belief.
You should review Title 50 Parts 10, 13, and 22.60 of the Code of Federal Regulations (CFR). You are responsible for reviewing
and understanding these regulations before you request and accept a permit. You must be at least 18 years old to apply for a
migratory bird permit. Please read the pertinent regulations before you sign and submit your application.
Please provide the information requested below. If additional information needs to be provided that does not fit in the designated
spaces, 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.
You should be as thorough and specific as possible in your responses. Incomplete applications will be returned.
FOR RENEWAL APPLICATIONS: Please answer 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, and processing fees paid, or the renewal will not be processed.
Do not use this application if you wish to apply for a permit to obtain eagle parts from the National Eagle Repository. For
that permit, use Form 3-200-15a, Eagle Parts for Native American Religious Purposes Permit Application - First Order/
ReOrder.

SECTION E.
Questions
1) Attachments - In additions to this form, you should also attach the following to complete your application:

a) Attach a completed Certification of Enrollment documenting the Principal Officer’s enrollment in a federally
recognized tribe. The certificate must be signed by the tribal official who is authorized to certify that an individual is
a duly enrolled member of that tribe, and must include the official title of that certifying official. A Certification of
Enrollment form is included with this application.
b) Please designate if collection of live eagles will occur on Tribal lands. If not on Tribal lands, attach a signed
statement of consent from the landowner or managing official responsible for the land where the live eagle(s) will
be collected.

2) Any permit issued as a result of this application is not valid unless you also have any required State or tribal permits or
approvals associated with the activity. Have you obtained all required State or tribal permits or approvals to conduct this
activity?

Yes, Have Attached
None Required
Have Applied, Will Provide Upon Request

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OMB Control No. 1018-0167
Expires 07/31/2023

Form 3-200-77 (Rev. 02/2020)
U.S. Department of the Interior

Disclaimer: Whereas the U.S. Fish and Wildlife Service (we) will do what we can to protect any information that you identify as
confidential or private under one of the Freedom of Information Act exemptions that may be used to protect information from
disclosure (5 U.S.C. 552(b)), we cannot guarantee that we will not ultimately have to disclose the information.
If your religious beliefs do not permit you to reply to any of the questions below, please provide a signed statement identifying the
particular question or questions at issue and certifying that providing the information requested would substantially burden the exercise
of your religion. If we are unable to adequately evaluate your application on the basis of the information you provide, further inquiry may be
necessary.
3) A description of the live eagle(s) to be taken from the wild:
a) Species Requested
Bald Eagle
Golden Eagle
b) For each age group, enter the quantity requested to be taken:
Eggs

Immature

Nestlings

Adult

4) What season of year will the eagle(s) be taken?
Winter

Spring

Summer

Fall

Other:
Specify Dates:

5) Will the eagle(s) be (check one):
Collected live, or

Killed in the wild?

6) Will live eagles be held in captivity?
No, live eagle(s) will not be held in captivity.
Yes. If “yes,” how long will they be held in captivity?
(Live eagles must be held under humane and healthful conditions. If longer than 1 year, you will be required to apply a
permit to hold live eagle in possession for your religious purposes, Form 3-200-78.)
7) Will remains, parts, or feathers of the eagle(s) be retained in your possession a year or more after the eagle(s) is taken from
the wild?
Yes (If Yes, we may need to issue an additional separate lifetime permit for possession of the remains.)
No
8) All eagles held under this permit will be used for Indian Religious Purposed (per 50 CFR 22.22)
Yes
No

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Form 3-200-77 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires 07/31/2023

9) The State, County, and locality (or Tribal lands) where the eagle collection will occur:

10) Please explain why take of a live eagle(s) from the wild is necessary and why eagle remains, parts, or
feathers from another source will not suffice.

11) 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 address where your records will be kept?
Yes

No. If "no", provide
physical address

12) I acknowledge that I have read the FAQ, Instructions, and Additional Information; and have accessed the page with the Return
Addresses to obtain the address 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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OMB Control No. 1018-0167
Expires 07/31/2023

Form 3-200-77 (Rev. 02/2020)
U.S. Department of the Interior

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), 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. 1018-0167.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 8 hours (reporting) and 2 hours (recordkeeping)
Original submission - electronic: 7 hours (reporting) and 2 hours (recordkeeping)
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.
FREEDOM OF INFORMATION ACT
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 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 nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

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