Marine Mammal Authorization Program Registration Form

MARINE MAMMAL AUTHORIZATION PROGRAM
Registration Form
Regulations implementing section 118 of the Marine Mammal Protection Act (50 CF R 229.4) requires the owner of a commercial fishing
vessel engaged in a Category I or II fishery to obtain an authorization for the incidental take of marine mammals. Failure to obtain an
authorization, or to maintain a current and valid authorization, shall subject vessel ow ners to the penalties of the Marine Mam mal
Protection Act. If y ou will be participating in one of the Category I or II fisheries listed on the insert of this application, complete the
following:
Please PRINT LEGIBLY and in CAPITAL LETTERS, all responses in the blocks provided. See page 6 for complete instructions.
VESSEL NAME

VESSEL STATE REG. NO. / COAST GUARD DOC. NO.

STATE

HOME PORT OF VESSEL CITY

LENGTH (Ft)

COMM. VESSEL LIC. NO.

LAST NAME OF PRIMARY VESSEL OWNER

FIRST NAME OF PRIMARY VESSEL OWNER

M.I.

LAST NAME OF SECONDARY VESSEL OWNER

FIRST NAME OF SECONDARY VESSEL OWNER

M.I.

CORPORATE NAME (if applicable)

DATE OF INCORPORATION (if applicable)

MAILING ADDRESS (for business correspondence)

CITY

STATE

TELEPHONE NUMBER (including area code)

ZIP CODE

FAX NUMBER (including area code)

PRIMARY VESSEL OWNER
TAX IDENTIFICATION NUMBER/
SOCIAL SECURITY NUMBER

PRIMARY VESSEL OWNER
DATE OF BIRTH

SECONDARY VESSEL OWNER
TAX IDENTIFICATION NUMBER/
SOCIAL SECURITY NUMBER

SECONDARY VESSEL OWNER
DATE OF BIRTH

This information is used to verify the identity of the applicant(s) and to accurately retrieve confidential records related to federal permits. The primary
purpose for requesting the SSN/TIN is for the collection and reporting on any delinquent amounts arising out of such person’s relationship with the
government pursuant to the Debt Collection Improvement Act of 1996 (Public Law 104-134). Personal information is confidential and protected under the
Privacy Act (5 U.S.C. 552a). Business information may be disclosed to the public.
LAST NAME OF OPERATOR (if different than owner)

FIRST NAME OF OPERATOR

M.I.

MAILING ADDRESS (for business correspondence)

CITY

STATE

ZIP CODE
-

FAX NUMBER (including area code)

TELEPHONE NUMBER (including area code)

For Administrative Use Only:
M.O.

Check

No. ____________ Received B

y: ___________________ Date: _________________

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Certificate Issued By:

_________

Date:

____________

OMB Control No. 0648-0293 (expires 7/31/2012)

MARINE MAMMAL AUTHORIZATION PROGRAM
Certification
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY, THAT I AM THE OWNER OF THE ABOVE NAMED VESSEL
(OR NON-VESSEL FISHING GEAR), OR THAT I AM AUTHORIZED TO REGISTER FOR THIS AUTHORIZATION ON
BEHALF OF THE OWNER, THAT I HAVE REVIEWED ALL INFORMATION CONTAINED IN THIS DOCUMENT, AND
THAT IT IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

_________________________________________________________
Signature

_________________________________________
Date

IF THIS REGISTRATION IS SIGNED BY A PERSON OTHER THAN THE OWNER OR AUTHORIZED REPRESENTATIVE OF THE ABOVE-NAMED
VESSEL, PLEASE COMPLETE THE FOLLOWING:
LAST NAME OF REPRESENTATIVE

FIRST NAME OF REPRESENTATIVE

M.I.

ADDRESS

STATE

CITY

ZIP CODE

Mail this completed registration form,
along with a check in the amount of $25.00, payable to the National Marine Fisheries Service,
to the nearest NMFS regional office listed below.
(Please allow 30 days for processing):

Marcia Hobbs
NMFS Northeast Region
One Blackburn Dr
Gloucester, MA 01930
978-281-9328
e-mail: Marcia.Hobbs@noaa.gov

Teletha Griffin
NMFS Southeast Region
9721 Executive Center Dr North
St. Petersburg, FL 33702
727-570-5312
e-mail: Teletha.Griffin@noaa.gov

Lyle Enriquez
NMFS Southwest Region
501 West Ocean Blvd, Suite 4200
Long Beach, CA 90802
562-980-4025
e-mail: Lyle.Enriquez@noaa.gov

This collection of information is mandated by the Marine Mammal Protection Act (16 U.S.C. 1387) and by implementing regulations contained at 50 CFR 229. 4. The
information supplied on this form will be used by the National Marine Fisheries Service to approximate fishing effort in various fisheries which impact marine mammal
populations in U. S. waters and to aler t vessel owner s of applicab le rules and r egulations regarding the incidental take of m arine mammals in com mercial fishing
operations. Certain information supplied on this form may be considered proprietary and therefore subject to data confidentiali ty restrictions of 50 CFR Par t 229.11.
Public reporting burden for this collection of information is estimated to average 15 minutes per response for new applications and 9 minutes per response for renewals,
including the time for reviewing 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 this burden, to
Director, Office of Pr otected Resources, National Marine Fisheries Service, 1315 E ast-West Highway, Silver Spring, MD 20910, (301) 713-2332.
The National Marine Fisheries Service may not conduct or sponsor, and a per son is not r equired to respond to, a collection of i nformation unless it display s a current
and valid OMB control number. The OMB Control number for this form is 0648-0293, which expires on 7/31/2012.

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OMB Control No. 0648-0293 (expires 7/31/2012)

MARINE MAMMAL AUTHORIZATION PROGRAM
Registration Form Instructions
VESSEL NAME: Enter the name of the vessel as it is identif ied for commercial fishing operations. For non-vessel
fisheries, leave this blank. A SEPARATE REGISTRATION FORM IS REQUIRED FOR EACH VESSEL, OR EACH FIXED
GEAR SITE FOR A NON-VESSEL FISHERY.
LENGTH (FT): Enter the overall length of the vessel, in feet.
HOME PORT OF VESSEL - CITY, STATE: Enter the city and state where the vessel is registered.
VESSEL STATE REGISTRATION NO./COAST GUARD DOCUMENTATION NO.: Enter either the vessel’s state
registration number OR Coast Guard Documentation
number. One of these numbers must be
provided or an
authorization cannot be granted. In the case of non-vessel fisheries, enter the site permit or set-net license number.
STATE COMMERCIAL VESSEL LICENSE NO.: Enter the vessel’s state commercia l fishery vessel license number, if
applicable. In Alaska, this is the ADFG commercial fis
hery vessel license number. In California, this is the CDFG
commercial fishery vessel license number.
PRIMARY VESSEL OWNER: Enter the vessel owner’s last name, first name, and middle initial.
SECONDARY VESSEL OWNER: If the vessel is jointly owned, enter the secondary vessel owner’s last name, first name,
and middle initial.
CORPORATE NAME: If the vessel is owned by a corporation, enter the full legal name of that corporation.
DATE OF INCORPORATION: If the vessel is owned by a corporation, enter the date it was incorporated.
MAILING ADDRESS, CITY, STATE, ZIP CODE, TELEPHONE NUMBER: Enter the address that the vessel owner or
corporate owner uses for business correspondence. Enter the vessel owner’s phone number, including area code.
SOCIAL SECURITY NUMBER: If the vessel owner participates in an Alaska
security number.

Fishery, enter the vessel owner’s social

DATE OF BIRTH: Enter the vessel owner’s date of birth.
OPERATOR: If the operator of the vessel is different than the
middle initial.

owner, enter the operator’s last name, first name,

and

MAILING ADDRESS, CITY, STATE, ZIP CODE, and TELEPHONE NUMBER: Enter the address that the operator of the
vessel uses for business correspondence. Enter the vessel owner’s phone number and fax number, including area code.
FISHERIES CHECKLIST: Check the circle corresponding to the fishery or fisheries in which you will participate during the
next year. Registration for fisheries marked with an aste risk (*) has been integrated with existing state and Federal
permitting and licensing programs. If you have a valid permit to par ticipate in any of the fisheries marked with an asterisk
(*), you are not required to submit an MMAP registration fo rm and processing fee in order to receive a Marine Mammal
Authorization Certificate. However, if you participate in any of the fisheries not marked with an asterisk (*), you must
complete this form and mail it to NMFS, along with the $25 pr ocessing fee. If you will not be participating in any of the
fisheries identified on the checklist, you do not need to fill out this registration form.
CERTIFICATION: The vessel owner or operator must sign and date the registration form. If someone filled out the form
other than the vessel owner or operator, enter the representative’s full name and address.
MAILING INSTRUCTIONS: After completing the registration form, mail it, along with a check in the amount of $25,
payable to the National Marine Fisheries Service, to the nearest NMFS regional office address listed on page 4. A Marine
Mammal Authorization Program certificate or decal will be sent to you in the mail. The decal must be displayed on the port
side of the vessel’s cabin or hull, and the certificate must be in the possessi on of the vessel operator while engaged in
commercial fishing operations.
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OMB Control No. 0648-0293 (expires 7/31/2012)