Mothership Permit Application

OMB Control No. 0648-xxxx
Expiration Date: xx/xx/xxxx

MOTHERSHIPPERMIT
APPLICATION
PACIFIC COAST GROUNDFISH

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service, Northwest Region
Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

SECTION A – Applicant/Vessel Owner Information
1. Vessel Name

2. Vessel Owner □
Bareboat Charterer □ [check one]

3. USCG Doc or State Registration Number

4. Name

5. TIN or DOB

6. State Registered in, if business entity

7. Business Mailing Address (also list physical address for first receiver, if different)

8. Business Phone

(

Street or PO Box

)

9. Business Fax (optional)

(
City

State

10. Business Email (optional)

Zip Code

MS Permit Application Form – PAGE

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OMB Control No. 0648-xxxx
Expiration Date: xx/xx/xxxx

SECTION B – Preliminary Qualifying Data
Qualifying Criteria: In order to qualify for the MS permit, the mothership processor vessel given in
Section A must have processed at least 1,000 metric ton of whiting in the mothership sector in each of
any 2 years from 1997 – 2003.
Prequalified Applicant: Based on the extraction of Pacific whiting data from the NORPAC database,
NMFS has determined that the mothership processor vessel named in Section A processed whiting in
the mothership sector in the qualifying years listed below:
Year

Amount of Whiting Processed (in Metric Tons)

1997
1998
1999
2000
2001
2002
2003
Note: If you did not receive this form as a prequalified applicant, and you believe you qualify for a MS
permit, you must submit a complete application to NMFS by the deadline date. Please provide the
amount of whiting processed by the vessel given in Section A for each of the qualifying years (if the
vessel did not process any whiting in a given year insert a zero). You must provide with the application
copies of NMFS whiting observer records or other credible information that establishes that the vessel
meets the qualifying criteria.

MS Permit Application Form – PAGE

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OMB Control No. 0648-xxxx
Expiration Date: xx/xx/xxxx

SECTION C - CERTIFICATION OF APPLICANT AND NOTARY
This section must be completed by a notary to certify that the individual(s) have satisfactorily identified themselves.

Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant and completed
this form, and the information contained herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Authorized Representative

Date

Printed Name of Authorized Representative (NOTE: attach authorization, if needed)

Notary Public Signature

“ ATTEST

Affix Notary Stamp or Seal Here

Date Commission Expires

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR 904, a civil
penalty of up to $140,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.
PRIVACY ACT STATEMENT: Your DOB and/or TIN are confidential and protected under the Privacy Act. Provision of your DOB or TIN is mandatory as part of
this collection. The primary purpose for requiring the DOB and/or TIN is to verify the identity of individuals/entities doing business with the government to provide a
unique identification for assistance to comply with the Debt Collection Improvement Act of 1996 (Public Law 104-134) and for enforcement activities. The
information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registration for United States Federally Regulated
Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065).
PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 1.0 hours per response, including the time for reviewing the
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to NOAA/National
Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115.
Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216100, Protection of Confidential Fisheries Statistics. Phone number, fax, email, TIN, and DOB are not released to the public. The names of individuals who have
an ownership interest in an entity that owns a permit, vessel or processing plant and the actual percentage of ownership are considered business confidential and
are not released to the public.

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