Form 3-200-76 Federal Fish and Wildlife Permit Application Form - Expo

Expires XX/XX/XXXX
OMB No. 1018-XXXX

Department of the Interior
U.S. Fish and Wildlife Service
Federal Fish and Wildlife Permit Application Form

Return to: Division of Management Authority (DMA)
U.S. Fish and Wildlife Service
4401 N. Fairfax Drive, Room 700
Arlington, VA 22203
1-800-358-2104 or 703-358-2104

Type of Activity:
Export of Caviar or Meat of Paddlefish or Sturgeon Removed from the Wild
(CITES)

Complete sections A OR B, and C and D of this application. Note: if a field is "gray," no answer is required. Application will not be considered
complete without all sections. See additional instructions on attached pages.

Complete if applying as an individual (Provide a U.S. address)

A.
1.a. Last name

1.b. First name

2.a. Street address (line 1)

2.b. Street address (line 2)

3.a. City

3.b. Province

4. Date of birth (mm/dd/yyyy)

3.d. Zip code/Postal code:

6. Occupation

7.c. Fax number

1.d. Suffix

2.c. Street address (line 3)

3.c. State

5. Social Security No.

7.b. Work telephone number

3.e. Country

7.a. Home telephone number

8. E-mail address

10. List any business, agency, organizational, or institutional affiliation associated with the wildlife
or plants to be covered by this permit (see C.1.)

B.

1.c. Middle name or initial

9. County
11. Doing business as (dba)

Complete if applying as a business, corporation, public agency or institution

1.a. Name of business, agency, or institution

1.b. Doing business as (dba)
2.b. Street address (line 2)

2.a. Street address (line 1)

3.b. Province

3.a. City

2.c. Street address (line 3)
3.c. State

3.d. Zip code

3.e. Country

4. Tax identification no.

5. Describe the type of business, agency, or institution and provide state of incorporation

6.a. Principal officer (President, director, etc) Last name

6.b. First name

6.c. Middle name or initial

7. Principal officer title:
9. Work telephone number

6.d. Suffix

8. Home telephone number
10. Fax number

11. E-mail address

12. County

C.

All applicants complete

1.

Do you currently have or have you had any Federal Fish and Wildlife permits? (For simplification, all licenses, permits, registrations, and certificates will be referred
to as a permit.)
Yes
If yes, list the number of the most current permit you have held: ___________________________________
No
Have you obtained all required State, Federal, or foreign government approval(s) to conduct the activity you propose?

2.

Yes

If yes, provide a copy of the approval(s).

Have applied

Not required

3.

Enclose check or money order payable to the U.S. FISH AND WILDLIFE SERVICE for the amount indicated on page 2. Institutions which qualify under 50
CFR 13.11(d)(3) may be exempt from the application processing fee.

4.

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.

5.

Signature (in blue ink) of applicant/person responsible for permit in Section A or B. (Photocopied signatures are not accepted.)

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Please continue to Section D on next page

7. Date (mm/dd/yyyy):

D.

Export of Caviar or Meat Obtained from Paddlefish or Sturgeon Removed from the Wild (CITES)

NOTE: To ensure the most applicable application is being submitted, please review the following before completing this
form. To request export of live specimens removed from the wild use form 3-200-27; export of aquacultured specimens
use form 3-200-24; re-export of specimens use form 3-200-73; or export or re-export of species listed under the U.S.
Endangered Species Act use form 3-200-37.
Please provide the following information. If necessary, use a separate sheet of paper. On all attachments or additional
pages, please indicate the application question number you are addressing. Please do not use staples.
1.

What type of authorizations are available to me as an exporter?
a. Single shipment for export. The processing fee is $100 per application. Provide the name and address of
person/facility receiving the shipment (if self, provide address abroad).
Name:
Address
City, Country, Postal Code
b. Multiple shipments of identical amounts. For multiple shipments of identical amounts, the Service can
establish a master file. If the master file is approved you would need to obtain single-use permits, valid for 6
months, for each export (50 CFR 13.11, see attached). The processing fee is $200 and is $5 for each permit
issued from the master file (e.g., shipments to a cruise ship). To obtain single use permits from the master file,
complete below:
i.
Total amount you are requesting to be authorized: ____________.
ii. How many permits do you anticipate using in the next 6 months? _________. (Provide $5 for each 6month permit; you may provide this after the master file is approved).
iii. Amount you are requesting on each permit:
____________ (must be identical for each permit.)
(EXAMPLE: TOTAL AMOUNT = 100 KG; 4 PERMITS; 25 KG EACH.)
iv. Note, you may either fill in the recipient at the time of export or you may indicate a recipient in block A
above.

2.

For each product to be exported, provide:
a.
Scientific name (genus, species, and if applicable, subspecies) and common name of the fish:
b.
State(s) of harvest of source specimens:
c.
Product description (caviar or meat):
.
d.
Weight (provide pounds and metric units) :
.
e.
Shipping containers to be used (e.g., jars, tins, buckets) and sizes (provide units):
f.
Shipment will be fresh, frozen, or pasteurized (circle one), or other (describe) _________________
g.
If caviar, provide list of labels (see enclosed caviar labeling requirements).
h.
Current location of specimen(s): _________________________________________.

3.

What is the purpose of the export? Check one:  Commercial  Personal

4.

Does this application request authorization to export a portion of a product(s) that was authorized under a previous
permit?
a.
If no, continue to question 5.
b.
If yes, complete c. and d. below and continue to questions 11-14.
c.
Provide a copy of the cleared 3-177 declaration form obtained when you exported the previous portion of
product, and complete and sign (in ink) the following statement:
d.
I hereby certify that the product pertaining to this current application is a portion of the product previously
authorized for export under permit number _______________________.
(fill in permit number)

.

.
.

 Other: _______________

Signature and date ____________________________________________________________________.
Application ID # (refer to no. D.15) ____________________
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Please continue to Section D on next page

Numbers 5-10 must be answered for the entire quantity of product(s) listed in your application. By signing this
application, you are certifying that to the best of your knowledge and belief all the information provided in support of this
application is complete and accurate, including any and all information provided about suppliers, dealers, and fishers.
5.

List ALL intermediary suppliers’ and/or dealers’ names and addresses below and weight of product obtained from
each (attach additional sheets of paper as necessary):
Name:
Address:
City, State, Zip Code:
Total weight of product
supplied:

6.

List ALL fishers’ full names and addresses below and weight of product obtained from each (attach additional
sheets of paper as necessary):
Name:
Address:
City, State, Zip Code
Total weight of product
supplied:

NOTE for numbers 7-10: If you obtained product(s) from a supplier or dealer, you must obtain, and supply to us,
all of the required information from the supplier. All supporting documentation must be submitted in an
organized format; otherwise the application will not be processed and will be returned to you. Documentation
should be organized first by State of harvest (i.e, all documentation for fish harvested from a particular state must
be clipped together). Within each State packet, the documentation should be grouped by fisher (i.e., every invoice
for a particular fisher must be clipped together).
7.

Provide a copy of the appropriate commercial buyer’s license(s).

8.

For each fisher listed above, provide a copy of the current license(s), permit(s), or other documents issued by the
State or local wildlife authorities approving the commercial fishing activities.

9.

Provide copies of each fisher’s State harvest report for the product(s) to be exported. The harvest report should
include, at a minimum, the following information. If any of this information is not listed on the fisher’s harvest
report, the information must be provided separately for each fisher on an attached sheet of paper. For each fisher
provide the:
a. Dates the fish were harvested;
b. Harvest location(s), including the State, county(ies), body of water, AND the nearest mile marker or boat ramp
to each harvest location; and
c. Gear used to harvest or collect the fish.

10.

Provide copies of documentation showing the transfer of ownership (e.g., dated sales receipts/invoices) of the
product from each fisher or supplier to you. If you received the product from a supplier(s) or source other than the
harvesters of the fish, provide documentation demonstrating the history of transactions (chain of ownership of the
product) from the fisher(s) to you. You must be able to provide documentation for EACH change in ownership
from the time of harvest until the time you purchased the product.

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Application ID # (refer to no. D.15) ____________________

11.

Enter the U.S. port through which the export will occur. Port: ___________________________. If no port is
indicated, you must use a port designated for the export of wildlife (see enclosed) .

12.

Address where you wish permit mailed (if different than page 1):
_________________________________________________________________________.

13.

If you wish the permit to be mailed other than by regular mail, provide air bill, pre-paid envelope, or billing
information ________________________________________________________________________________.

14.

Who should we contact if we have questions about the application? (Include name, phone number, and email):
____________________________________________________________________________. Note that it is our
policy to contact the applicant only if additional information is required.

15.

OPTIONAL: If you are submitting multiple applications concurrently and/or if you are having a supplier or
wholesaler submit information supportive of your application to us, you may designate a unique number to identify
your application until a PRT number is assigned by our office for your tracking purposes ___________________.
List this number at the top of your application pages.

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PERMIT APPLICATION FORM INSTRUCTIONS
The following instructions pertain to the standard permit form 3-200 that must be completed as an application for a U.S. Fish and Wildlife Service or
CITES permit. The General Permit Procedures in 50 CFR 13 address the permitting process. For simplification, all licenses, permits, registrations,
and certificates will be referred to as a permit.
•

Complete all appropriate blocks/lines/questions in Sections A OR B, and C and D. Print clearly or type in the information. An
incomplete application may cause delays in processing or may be returned to the applicant. Note: if a field is "grayed in", no answer is
required.

•

Sign the application in blue ink and send the original to the address at the top of the application. Faxes or copies of the original signature
will not be accepted.

•

Please plan ahead. Allow at least 60 days for your application to be processed (50 CFR 13.11). However, some applications may take
longer than 90 days to process. Applications are processed in the order they are received.

•

Additional forms and instructions are available from http://permits.fws.gov/ .

Most of the application form is self-explanatory, but the following provides some assistance for completing the form.
COMPLETE EITHER SECTION A OR SECTION B:
Section A.

"Complete if applying as an individual" - Enter the complete name of the responsible individual who will be the permittee if a
permit is issued. Enter personal information that identifies the applicant. All blocks must be completed. If you are applying on
behalf of a client, the personal information must pertain to the client; and a document evidencing power of attorney must be
included with the application.

Section B.

"Complete if applying as a business, corporation, public agency, or institution" - Enter the complete name and address of the
business, agency or institution that will be the permittee if a permit is issued. Give a brief description of the type of business the
applicant is engaged in, the name and phone number of the person in charge (i.e., principal officer), and if the company is
incorporated, the State in which it is incorporated.

ALL APPLICANTS COMPLETE SECTION C:
Section C.1

"Do you currently have or have you had any Federal Fish and Wildlife permits? List the number(s) of your most current FWS or
CITES permit or the number of the most recent permit if none are currently valid. If applying for a renewal of a CITES permit, the
original permit must be returned with this application.

Section C.2

"Have you obtained all required State, Federal or foreign government approval to conduct the activity you propose?" (Please
be aware that there may be other requirements necessary to conduct this activity such as a hunting license, import permit, or collection
permit.) If "yes," list the state, Federal or foreign countries involved and type of document required. Include a copy of these
documents with the application. If you have applied for the documents, check the “have applied” box and list the state, Federal or
foreign countries involved and type of documents required. If the proposed activity is not regulated check "not required."

Section C.3

"Check or money order (if applicable)" There is an application processing fee unless you are applying as a Federal, State or tribal
government agency or you are an individual or institution under contract to such agency for the proposed activities. (See 50 CFR
13.11(d)(3) for fee schedule.) Proof of status as a Federal, State or tribal government agency or contractor to such agency should
accompany your application. The application processing fee is assessed to partially cover the cost of processing a request. The fee
does not guarantee the issuance of a permit. It will not be refunded regardless of whether a permit is issued, abandoned, or denied.
See the accompanying section APPLICATION PROCESSING FEE for the fee to process this application. Make your check or
money order payable to the “U.S. Fish and Wildlife Service” and attach it to the application form.

Section C.4

"CERTIFICATION" The individual identified in Section A, the principal officer named in Section B, or person with a valid
power of attorney (documentation must be included in the application) must sign and date the application in blue ink. This
signature binds the applicant to the statement of certification. This means that you certify that you have read and understand the
regulations that apply to the permit. You also certify that everything included in the application is true to the best of your knowledge.
Be sure to read the statement and re-read the application and your answers before signing.

ALL APPLICANTS COMPLETE SECTION D:
Provide any required additional information outlined in Section D. of the application form. Be as complete and descriptive as possible. If there is
any doubt as to the information's relevance, include it with the application. Please do not send videotapes or DVDs.

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APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT
Paperwork Reduction Act and the Privacy Act – Notices
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 gathering of information on fish and wildlife is authorized by:
a.
Bald and Golden Eagle Protection Act (16 U.S.C. 668), Title 50 Part 22 of the Code of Federal Regulations (CFR);
b.
Endangered Species Act of 1973 (16 U.S.C. 1531-1544), Title 50 CFR Part 17;
c.
Migratory Bird Treaty Act (16 U.S.C. 703-712), Title 50 CFR Part 21;
d.
Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), Title 50 CFR Part 18;
e.
Wild Bird Conservation Act (16 U.S.C. 4901-4916), Title 50 CFR Part 15;
f.
Lacey Act (18 U.S.C. 42); Injurious Wildlife, Title 50 CFR Part 16;
Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249); Title 50 CFR Part 23.
g.
h.
General Provisions, Title 50 CFR Part 10;
i.
General Permit Procedures, Title 50 CFR Part 13; and
j.
Wildlife (Import/export/transport), Title 50 CFR Part 14.

2.

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.
Response is not required unless a currently valid Office of Management and Budget (OMB) control number is displayed.

3.

Certain applications for permits authorized under the Endangered Species Act of 1973 (16 U.S.C. 1539) and the Marine Mammal Protection Act of 1972 (16
U.S.C. 1374) will be published in the Federal Register as required by the two laws.

4.

Routine use disclosures outside the Department of the Interior may be made without the consent of an individual if the disclosure is compatible with the purposes
for which the record was collected. (Ref. 68 FR 52611, September 4, 2003) Disclosures outside the DOI may be made under the routine uses listed below
without the consent of the individual if the disclosure is compatible with the purposes for which the record was collected.
a.
To subject matter experts, and State, Federal, local, and foreign agencies, for the purpose of obtaining advice relevant to making a decision on an application
for a permit or when necessary to accomplish a FWS function related to this system of records.
b.
To the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment or notice of the decision on
a permit application.
c.
To Federal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied to assure compliance with all
applicable permitting requirements.
d.
To Captive-bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share information on the captive
breeding of these species.
e.
To Federal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and injured birds under the Migratory
Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking a permitted rehabilitator with whom to
place a sick, injured, or orphaned bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds.
f.
To the Department of Justice (DOJ), or a court, adjudicative, or other administrative body or to a party in litigation before a court or adjudicative or
administrative body, under certain circumstances;
g.
To the appropriate Federal, State, tribal, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing, or implementing
statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we need to monitor
activities associated with a permit or regulated use.
h.
To a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
i.
To the General Accounting Office or Congress when the information is required for the evaluation of the permit programs.
j.
To provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise a
Federal claim against the debtor, or to consumer reporting agencies to prepare a commercial credit report for use by the FWS.

5.

For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth date, etc.)
will be removed prior to any release of the application.

6.

The public reporting burden on the applicant for this information collection varies depending on the activity for which a permit is requested. The relevant burden
for this permit application is 3 hours. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing
the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and
Wildlife Service, Mail Stop 222, Arlington Square, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.
Freedom of Information Act – Notice

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 non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.13(c)(4), 43 CFR
2.15(d)(1)(i)].
Application Processing Fee
The fee to process this application is $200 for a master file and $5 for each permit issued from that file; OR for a single permit, $100 processing fee. Checks should be
made payable to "U.S. Fish and Wildlife Service." Fees for renewals and amendments may vary; see fee schedule at 50 CFR 13.11(d). The processing fee will not be
refunded regardless of whether a permit is issued, abandoned, or denied. The fee schedule does not apply to any Federal, State, local, or tribal government agency or
individual or institution under contract to such agency for the proposed activities

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