Form 3-1383-EZ General Activities Special Use Permit Simplified Applica

FWS Form 3-1383-EZ (Rev. 11/2025)
U.S. Department of the Interior

OMB Control Number 1018-0102
Expires ##/##/20##

GENERAL ACTIVITES
SIMPLIFIED SPECIAL USE PERMIT APPLICATION
National Wildlife Refuge System

Section 1: Site Information
Refuge:

For Official Use Only:
Permit #:

Address:
E-Mail:

Station #:

Phone #:

Permit term:

from

to

Note: We do not require all information for each use. This form is intended for activities that are unlikely to require insurance, staging of equipment,
additional USFWS staff, or overnight stays. See instructions at the end of the notice and contact the refuge to determine applicability of a particular item.

Section 2: Applicant Information
1) Full Name:

2) Organization:

3) Physical Address:
City/State/Zip
4) Mailing Address:
City/State/Zip
6 ) E-Mail:

5) Phone #:

Section 3: Activity Information
7a) Choose an Activity Type:

Special Access

Educational Group

Ceremonial Activity

Wood Cutting

Fruit Picking/Gathering

Boat Mooring/Access

Other

7b) Specify activity if “Other” was chosen:
7c) How many people will be on-site for the activity?
8) Describe the activity, access timeline, and frequency of access:

15) Specifically identify location(s) and/or attach a map:

Sign, date, and return this form to the refuge for processing. By signing this application, I agree my operations will conform to the information I have
provided in this application, and I understand that any deviations or changes to this information must receive prior written approval.

Signature of Applicant:

Date of Application:

OMB Control Number 1018-0102
Expires ##/##/20##

FWS Form 3-1383-EZ (Rev. 11/2025)
U.S. Department of the Interior

NOTICES
No Members of Congress or Resident Commissioner shall participate in any part of this contract or to any benefit that may arise from it, but this provision shall not pertain to
this contract if made with a corporation for its general benefit.
The Permittee agrees to be bound by the equal opportunity “nondiscrimination in employment” clause of Executive Order 11246.

PRIVACY ACT STATEMENT

Authority:

The information requested is authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) and the Refuge Recreation Act (16
U.S.C. 460k-460k-4).

Purpose:

To collect the applicant’s information to process permits allowing for commercial activities such as: guiding hunters, anglers or other outdoor users; commercial
filming; agriculture; rental of cabins and trapping while on the National Wildlife Refuge System.

Routine Uses: The information will be used by the refuge’s administrative office for processing Commercial Activity Special Use permits.
routine uses maybe found in the Systems of Records Notice, FWS-5 National Wildlife Refuge Special Use Permits.

More information about the

Disclosure:

Providing the information is voluntary. However, submission of information is required to process and approve commercial activity usage on the National
Wildlife Refuge System.

PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to evaluate the qualifications, determine eligibility, and document permit applicants
and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. The information that you provide is required to obtain or retain a benefit;
however, failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. False, fictitious, or fraudulent statements or
representations made in the application may be grounds for revocation of the Special Use Permit and may be punishable by fine or imprisonment (18 U.S.C. 1001). 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 information collection and assigned control number 1018-0102.

ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 15minutes
Original submission - electronic: 12 minutes
Amended submission - paper based: 9 minutes
Amended submission - electronic: 9 minutes
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.

GENERAL CONDITIONS AND REQUIREMENTS
Responsibility of Permittee: The permittee, by operating on the premises, shall be considered to have accepted these premises with all facilities, fixtures, or improvements in
their existing condition as of the date of this permit. At the end of the period specified or upon earlier termination, the permittee shall give up the premises in as good order and
condition as when received except for reasonable wear, tear, or damage occurring without fault or negligence. The permittee will fully repay the Service for any and all
damage directly or indirectly resulting from negligence or failure on his/her part, and/or the part of anyone of his/her associates, to use reasonable care.
Operating Rules and Laws: The permittee shall keep the premises in a neat and orderly condition at all times, and shall comply with all municipal, county, and State laws
applicable to the operations under the permit as well as all Federal laws, rules, and regulations governing national wildlife refuges and the area described in this permit. The
permittee shall comply with all instructions applicable to this permit issued by the refuge official in charge. The permittee shall take all reasonable precautions to prevent the
escape of fires and to suppress fires and shall render all reasonable assistance in the suppression of refuge fires.
Use Limitations: The permittee’s use of the described premises is limited to the purposes herein specified and does not, unless provided for in this permit, allow him/her to
restrict other authorized entry onto his/her area; and allows the U.S. Fish and Wildlife Service to carry on whatever activities are necessary for: (1) protection and maintenance
of the premises and adjacent lands administered by the U.S. Fish and Wildlife Service; and (2) the management of wildlife and fish using the premises and other U.S. Fish
and Wildlife Service lands.
Transfer of Privileges: This permit is not transferable, and no privileges herein mentioned may be sublet or made available to any person or interest not mentioned in this
permit. No interest hereunder may accrue through lien or be transferred to a third party without the approval of the Regional Director of the U.S. Fish and Wildlife Service and
the permit shall not be used for speculative purposes.
Compliance: The U.S. Fish and Wildlife Service’s failure to require strict compliance with any of this permit’s terms, conditions, and requirements shall not constitute a waiver
or be considered as a giving up of the U.S. Fish and Wildlife Service’s right to thereafter enforce any of the permit’s terms or conditions.
Conditions of Permit not Fulfilled: If the permittee fails to fulfill any of the conditions and requirements set forth herein, the U.S. Fish and Wildlife Service shall retain all money
paid under this permit to be used to satisfy as much of the permittee’s obligation as possible.
Payments: All payment shall be made on or before the due date to the local representative of the U.S. Fish and Wildlife Service by a postal money order or check made
payable to the U.S. Fish and Wildlife Service.
Termination Policy: At the termination of this permit the permittee shall immediately give up possession to the U.S. Fish and Wildlife Service representative, reserving,
however, the rights specified in paragraph 11 below. If he/she fails to do so, he/she will pay the U.S. Fish and Wildlife Service, as liquidated damages, an amount double the
rate specified in this permit for the entire time possession is withheld. Upon yielding possession, the permittee will still be allowed to reenter as needed to remove his/her
property as stated in paragraph 11 below. The acceptance of any fee for the liquidated damages or any other act of administration relating to the continued tenancy is not to
be considered as an affirmation of the permittee’s action nor shall it operate as a waiver of the U.S. Fish and Wildlife Service’s right to terminate or cancel the permit for the
breach of any specified condition or requirement.

OMB Control Number 1018-0102
Expires ##/##/20##

FWS Form 3-1383-EZ (Rev. 11/2025)
U.S. Department of the Interior

Revocation Policy: The Regional Director of the U.S. Fish and Wildlife Service may revoke this permit without notice for noncompliance with the terms hereof, or for violation
of general and/or specific laws or regulations governing national wildlife refuges, or for nonuse. It is at all times subject to discretionary revocation by the Director of the
Service. Upon such revocation the U.S. Fish and Wildlife Service, by and through any authorized representative, may take possession of said premises for its own and sole
use, and/or may enter and possess the premises as the agent of the permittee and for his/her account.
Damages: The U.S. Fish and Wildlife Service shall not be responsible for: any loss or damage to property including but not limited to crops, animals, and machinery; injury to
the permittee or his/her relatives or to the officers, agents, employees, or any other(s) who are on the premises from instructions; the sufferance from wildlife or employees or
representatives of the U.S. Fish and Wildlife Service carrying out their official responsibilities. The permittee agrees to hold the U.S. Fish and Wildlife Service harmless from
any and all claims for damages or losses that may arise to be incident to the flooding of the premises resulting from any associated government river and harbor, flood control,
reclamation, or Tennessee Valley Authority activity.
Removal of Permittee’s Property: Upon the expiration or termination of this permit, if all rental charges and/or damage claims due to the U.S. Fish and Wildlife Service have
been paid, the permittee may, within a reasonable period as stated in the permit or as determined by the U.S. Fish and Wildlife Service official in charge, but not to exceed 60
days, remove all structures, machinery, and/or equipment, etc., from the premises for which he/she is responsible. Within this period the permittee also must remove any other
of his/her property including his/her acknowledged share of products or crops grown, cut, harvested, stored, or stacked on the premises. Upon failure to remove any of the
above items within the aforesaid period, they shall become the property of the U.S. Fish and Wildlife Service.

INSTRUCTIONS FOR COMPLETING APPLICATION
You may complete the application portion verbally, in person, or electronically and submit to the refuge for review. Note: Please read instructions carefully as not all information
is required for each activity. Contact the specific refuge headquarters office where the activity is going to be conducted to determine applicability of a particular item. We may
add special conditions or permit stipulations to permit prior to approval.
1-6) Provide applicant full name, organization name (if applicable), physical and mailing address, phone, fax, and e-mail.
7a) Activity type: identify activity type (such as, special access, educational group visits, ceremonial activities, wood cutting, gathering or picking natural products such as
fruit or mushrooms, boat mooring and access, or other uses). Describe other uses if not one of the listed categories. Applicants in Alaska should contact the specific refuge
headquarters office where the activity is going to be conducted if you have questions regarding subsistence activities.
7b) Describe other use if not one of the listed categories or if other was selected in 7a.
7c) Describe how many people will be involved in the activity and will be present on-site.
8) Describe Activity: provide detailed information on the activity, including timing and occupancy timeline, frequency, how the activity is expected to proceed, etc. Contact the
specific refuge headquarters office where the activity is going to be conducted to determine applicability of this requirement.
9) Location: identify specific location (GPS coordinates preferred) if not at a named facility, and/or attach a map with location. Most repetitive activities may not require
identification of a location. In addition, permit renewals may not require a location if the activity is essentially unchanged from the previous permit. Contact the specific refuge
headquarters office where the activity is going to be conducted to determine if a location is required.
10) Print the application (if using the fillable version). Date and sign the application and return to refuge for processing. By signing this application, you agree your operations
will conform to the information you have provided in this application, and understand that any deviations or changes to this information must receive prior written approval. The
refuge official will review and, if approved, fill out a Special Use Permit, sign, and return a copy to you for signature and acceptance.

THIS APPLICATION FORM IS NOT VALID AS A PERMIT
BUT MAY BE USED AS A REFERENCE DOCUMENT ATTACHED TO THE OFFICIAL PERMIT.
ONLY OFFICIAL REFUGE PERSONNEL MAY ASSIGN A VALID PERMIT NUMBER AND PERMIT TERM
TO THIS APPLICATION FORM AFTER THE PERMIT HAS BEEN APPROVED.