Form 3-2001 Alaska Special Use Permit Application

U.S. DEPARTMENT OF THE INTERIOR
U.S. FISH AND WILDLIFE SERVICE, ALASKA REGION

ALASKA SPECIAL USE PERMIT
APPLICATION
OFFICE USE:
SUP #

_________

NOTICE:

In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of
1974 (5 U.S.C. 552a) please be advised that:
1. The permitting of compatible economic and public uses on lands of the National Wildlife Refuge System is authorized
by: (a) the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) as amended by the National Wildlife
Refuge System Improvement Act of 1997 (Pub. L. 105-57); (b) the Refuge Recreation Act (16 U.S.C. 460k-n); (c) Bald
Eagle Protection Act (16 U.S.C. 663a); (d) Endangered Species Act of 1973 (16 U.S.C. 1539); (e) Migratory Bird Treaty Act
(16 U.S.C. 703-711); (f) Marine Mammal Protection Act of 1972 (16 U.S.C. 1371-1383); (g) Lacey Act (18 U.S.C. 42 and
44); and (h) Tariff Classification Act of 1962 (19 U.S.C. 1202).
2. Public and economic uses of national wildlife refuges may be authorized upon a determination that such uses are
compatible with the purpose(s) for which the refuge was established and the mission of the National Wildlife Refuge
System, and are not inconsistent with public safety. The action also must be in accordance with provisions of all laws
applicable to the area, consistent with the principles of sound fish and wildlife management and otherwise in the public
interest.
3. The application form will be used by U.S. Fish and Wildlife Service personnel to evaluate the qualifications and
conclude the eligibility of the applicant. Consistent with 50 CFR 36.41(d)(2), applicants may present the application for
noncompetitively issued permits verbally, if he/she is unable to prepare a written application. Applicants are required to
provide their social security or taxpayer identification number for activities subject to collection of fees by the Service (31
U.S.C. 7701).
4. Routine use disclosures may also be made (1) to the U.S. Department of Justice when related to litigation or
anticipated litigation; (2) of information indicating a violation or potential violation of a statute, regulation, rule, order or
license to appropriate Federal, State, local or foreign agencies responsible for investigating or prosecuting the violation or
for enforcing or implementing the statute, rule, regulation, order or license; (3) from the record of an individual in
response to an inquiry from a Congressional office made at the request of that individual (42 FR 19083; April 11, 1977)
5. Information requested in this form is purely voluntary, but failure to answer questions may jeopardize eligibility to
receive permits. Response is not required unless a currently valid Office of Management and Budget (OMB) control
number is displayed.
6. The public reporting burden for this information collection varies based on the specific refuge use being requested.
The relevant burden estimate ranges from 20 minutes to 1.5 hours for each noncompetitively bid permit, to 30 hours for
each competitively awarded permit. This burden estimate includes 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 Collection Clearance Officer, Fish and Wildlife Service, Mail Stop 222,
Arlington Square, U.S. Department of the Interior, 1849 C Street, N.W., Washington, D.C. 20240.

FWS Form 3-2001
REV 07/06

OMB Control No. 1018-0014
Expires: XX/XX/XXXX

FOR OFFICE USE ONLY:
SUP # _____________________

1) Please type or print legibly in ink. Answer all questions completely or mark “N/A” if not applicable.

APPLICANT NAME:

__________________________________________________

BUSINESS NAME:

__________________________________________________

TAXPAYER IDENTIFICATION NUMBER, or
SOCIAL SECURITY NUMBER:

__________________________________________________

PRIMARY ADDRESS:
(Business Address)

__________________________________________________
__________________________________________________
__________________________________________________

ALTERNATE ADDRESS:

__________________________________________________
__________________________________________________
__________________________________________________

PRIMARY PHONE NUMBER:

__________________________________________________

ALTERNATE PHONE NUMBER:

__________________________________________________

DATES PHONE NUMBERS VALID:

__________________________________________________

FAX NUMBER:

__________________________________________________

E - MAIL ADDRESS:

__________________________________________________

AS AN APPLICANT, ARE YOU: (Mark one box with “X”)
{ } INDIVIDUAL
{ } CORPORATION
{ } PARTNERSHIP/ASSOCIATION
{ } GOVERNMENT/STATE AGENCY
{ } OTHER ___________________________________________________________________________________
If you are an INDIVIDUAL or PARTNERSHIP, are you also a citizen(s) of the United States?
YES
FWS Form 3-2001
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NO _____________
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2)
NATIONAL WILDLIFE REFUGE
Mark with an X the refuge you are submitting this application for:
Alaska Maritime NWR
Alaska Peninsula/Becharof NWR
Arctic NWR
Innoko NWR
Izembek NWR
Kanuti NWR
Kenai NWR

Kodiak NWR
Koyukuk/Nowitna NWR
Selawik NWR
Tetlin NWR
Togiak NWR
Yukon Delta NWR
Yukon Flats NWR

3)
SPECIAL USE PERMIT ACTIVITIES
Mark with an X the type of activity or use you are submitting this application for, and provide specific
information requested below:
Guided/Outfitted Hunting - Big Game. Specify species hunted:
Guided/Outfitted Hunting - Migratory Birds. Specify species hunted:
Guided/Outfitted Hunting - Small Game or Upland Birds. Specify species hunted:
Guided Sport Fishing. Specify species fished:
Guided River or Float Trips. Specify type of boat and if motorized or non-motorized:
Guided Recreation -Other. Specify type of activities guided:
Outfitted Recreation - Other. Specify type of activity and equipment provided:
Air Taxi - FAA certified, point to point aircraft transportation.
Air Transporter - Aircraft transportation to big game hunters in the field.
Transporter - Other. Specify mode of transportation provided (e.g., boat, horse, snowmachine, etc.):
Commercial Photography.
Other. Describe activity or use below:
Description of proposed activity or use:

Area(s) of use (delineate on USGS topographic maps if applicable):

Estimated starting and ending dates of proposed activity:

Maximum number of clients per day:
FWS Form 3-2001
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Per season:_________________________
OMB Control No. 1018-0014
Expires: XX/XX/XXXX

4) Will your business be operating aircraft (not hiring air taxis) within the Refuge?
NO
If so, will your business be operating aircraft under:
YES
(Check one)
FAA Regulations Part 91 (Incidental Air)
FAA Regulations Part 135 (Air Taxi)
(PLEASE PROVIDE A COPY OF YOUR FAA CERTIFICATION.)
List the make, model, wheel/ski/float, color and tail number of all aircraft you own/lease/operate that you will
use in your proposed activity.
MAKE

MODEL

WHEEL
(
)

SKI
(
)

FLOAT
(
)

COLOR

TAIL NUMBER

Name of Air Taxi(s) you plan to use: (Please note that air taxis you use for activities on Refuge lands/waters must
be permitted to operate on the Refuge.)

______________________________________________________________________________________________
5) Will your business be operating other modes of transportation or access to or within the Refuge?
NO________
YES
If so, list the type of vessel(s) or vehicle(s) and the maximum passenger capacity of the vehicles and/or vessels
(not aircraft) you plan to use within refuge boundaries.
TYPE VESSEL/VEHICLE

MAXIMUM CAPACITY

REGISTRATION NUMBER

6) We require you to carry liability insurance to provide protection for visitors you serve on refuges.
Applicants must obtain liability coverage BEFORE we can issue a Special Use Permit for commercial
visitor service activities. Refer to the enclosed Insurance Information Sheet for minimum coverage
requirements. You must name the U.S. Government as an additional insured.
Do you have current liability insurance? YES
NO
ATTACH A COPY OF THE INSURANCE CERTIFICATE.
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REV 07/06

OMB Control No. 1018-0014
Expires: XX/XX/XXXX

7) Within the past 5 years, has the company (entity) or any of the owners of the business been convicted, pled nolo
contendere, or forfeited collateral for any violations of State, Federal, or local law or regulations related to fish and
wildlife or permit activities?
YES
NO_________
8) Is the company (entity) or any of the owners of the business now under charges for any violation of State,
Federal, or local law or regulations related to fish and wildlife or permit activities?
YES
NO ________
9) Within the past 5 years, have any of your current or proposed employees been convicted, pled nolo contendere,
or forfeited collateral for any State, Federal or local law or regulations related to fish and wildlife or permit
activities: OR are they now under charges for any violation of state, federal or local law or regulations related to
NO
_
fish and wildlife or permit activities?
YES
10) IF YOU ANSWERED “YES” TO QUESTIONS # 7, 8 OR 9, PLEASE GIVE DETAILS IN THE SPACE
BELOW. For each violation, provide the: 1) Individual’s Name, 2) Date, 3) Charge, 4) Place, 5) Court, and 6)
Action Taken. (Use additional sheets if necessary.)
INDIVIDUAL’S NAME

DATE

CHARGE

PLACE

COURT

ACTION

11) If this application is in response to a prospectus for a competitively awarded permit, please provide a detailed
response which addresses, at a minimum, the following factors: proposed operations plan; complete above history
of violation related questions 7, 8, and 9 for the past 10 years; safety record, training and proposed safety plan;
documentation of experience and knowledge applicable to both the proposed activity and delineated use area or
general geographical area; complete list and description of property, equipment and accessories; and complete list
of clients for same or similar activities during the past three years. (Use separate sheets to complete this question.)
12) Provide a complete list of names, addresses and phone numbers of employees who will be assisting with permit
activities on the refuge. Also indicate in what capacity they will be operating (e.g., guide, pilot, camp cook, etc.)
Any employee, including the applicant, who will be operating a vehicle, aircraft, or vessel while carrying clients
must provide their State drivers license number, pilot certificate number, or applicable vessel operating license
number and indicate whether they have had any such licenses suspended or revoked, or have been convicted for
driving while under the influence of alcohol or drugs during the past five years. Please use separate sheet to
provide this information.
13) False, fictitious or fraudulent statements or representations made in this application may be grounds for
revocation of the Special Use Permit and may be punishable by fine or imprisonment (18 U.S.C. 1001). We will
consider all information you provide in reviewing this application.
14) Please attach a copy of your State business license and any applicable State or Federal licenses, certifications,
and registrations required for the activity you propose to conduct on the Refuge (e.g., State Big Game Guiding
License, State Transporter License, FAA Air Taxi Certificate, U.S. Coast Guard License, sport fish guide
registration, etc.).

SIGNATURE OF OWNER/AGENT
(Attach Proof of Agent )
FWS Form 3-2001
REV 07/06

PRINTED NAME

DATE

OMB Control No. 1018-0014
Expires: XX/XX/XXXX

*************************************************************************************************

FOR OFFICE USE ONLY
Check #

Check Amount:

Overpayment:

Additional Amount Needed:

Fee Not enclosed

WERE THESE DOCUMENTS ENCLOSED WITH APPLICATION?
AIRCRAFT INSURANCE:
YES NO
STATE BUSINESS LICENSE: YES NO

GENERAL LIABILITY INSURANCE:
OTHER LICENSES/CERTIFICATIONS:

YES
YES

NO
NO

MISSING DOCUMENTATION _________________________________________________________________________________
_____________________________________________________________________________________________________________

FWS Form 3-2001
REV 07/06

OMB Control No. 1018-0014
Expires: XX/XX/XXXX