Pacific Coast Groundfish First Receiver Site License App

OMB Control No. 0648 -0620; Expiration Date: 11/30/2013

FIRST RECEIVER SITE
LICENSE APPLICATION

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

PACIFIC COAST GROUNDFISH

Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

SECTION A – Applicant/First Receiver Information
1. State of Buyer License

2. Buyer License #

3. First Receiver Name (Buyer)

4. TIN or DOB

6. If business entity, state registered in:

7. Business Mailing Address

8. Business Phone

(
Street or PO BoxNumber

)

9. Business Fax (optional)

(
City

State

Zip Code

)

10. Business Email (optional)

12. Contact Business Phone (if different from
above)

11. First Receiver Contact Person/Name:

(

)

SECTION B – Receiving Facility Information (Physical Location of IFQ Landing)
1. Name of Owner of the Receiving Facility

2. TIN or DOB

3. Street Address (No P.O. Box numbers)

City

State

Zip Code

4. Business Phone

5.Business Fax

(

(

)

6. Business E-mail Address

)

9. Name of Plant Manager/Point of Contact at receiving facility

First Receiver Site License Application Page 2 of 3

OMB Control No. 0648 -0620; Expiration Date: 11/30/2013

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 that I
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.

First Receiver Site License Application Page 3 of 3