Trawl Rationalization Quota Share Permit Application

OMB control No. 0648-XXXXX Expires On: XX/XX/XXXX

Quota Share Permit 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/QS Permit Holder Information

Name of QS Permit Applicant:

TIN or DOB

Business Mailing Address (P.O. Box or street address)

City

State

Zip Code

Business Telephone Number:

Business Fax Number:

E-mail Address (if available):

Name of Designated Account Manager:

DOB:

Business Mailing Address (if different from applicant)

City

State

Zip Code

Business Telephone Number:

Business Fax Number:

E-mail Address (if available):

Section B – Applicant Eligibility Certification

Note: The applicant must be eligible to own a QS Permit (see 50 CFR 660.140). Please respond to the questions below:

Are you a U.S. citizen eligible to own and control a U.S. fishing vessel with a fishery endorsement? YES □ NO □

Are you a permanent resident alien eligible to own and control a U.S. fishing vessel with a fishery endorsement? YES □ NO □

Are you a corporation, partnership, association or other business entity established under the laws of the U.S. or any State that is eligible to own and control a U.S. fishing vessel with a fishery endorsement? YES □ NO □

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
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 216-100, 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.

OMB control No. 0648-XXXXX Expires On: XX/XX/XXXX

Quota Share Permit 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

Instructions

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to apply for a quota share (QS) permit. A person must have a valid QS permit and QS account in order to own and control QS.

Section A – Applicant/QS Permit Holder Information

The applicant must provide their full name as it will appear on the permit and date of birth (for individuals) or tax identification number (if a business entity). Please provide the business mailing address, business phone number, fax number and email address. The applicant must provide the name of the designated manager of the QS account. NMFS will mail to this individual all pertinent information concerning the establishment of the QS account, including the user identification and password for the account. The designated account manager will be recognized as the principal point of contact regarding the management of the QS account.

Section B -

Section C - Certification of Applicant and Notary:

The applicant or authorized representative must sign and date the form in the presence of a notary to certify that the individual(s) signing the form have satisfactorily identified themselves. By signing and dating the form, the applicant or authorized representative certifies that all information set forth in the form is true, correct, and complete to the best of the applicant's knowledge and belief. The form will not be considered without the authorized representative’s signature. The notary must sign and date this section, and affix notary stamp or seal.

If the If the applicant is business entity, the authorized representative must include a copy of the corporate resolution or other document authorizing the individual to sign and certify on behalf of the business entity.

.
Supplemental Documentation

The applicant must provide an ownership interest form with this application.

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