Marine National Monument Non-commerical fishing permit a

INSERT NOAA LOGO HERE	FEDERAL FISHING PERMIT APPLICATION FORM U.S. DEPARTMEMENT OF COMMERCE NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION NATIONAL MARINE FISHERIES SERVICE PACIFIC ISLANDS REGION	OMB Control No: 0648-XXXX Expiration Date: xx/xx/xxxx
	201x	Mail or deliver this application to: NMFS Pacific Islands Region Office ATTN: Permits 1601 Kapiolani Blvd., Suite 1110 Honolulu, Hawaii 96814-4700 Tel: (808) 944-2200

MARINE NATIONAL MONUMENT NON-COMMERCIAL FISHING PERMIT

Please Print Legibly. Items marked with * are required. Please fill in other items as completely as possible. Note required documents at bottom of page.

1.*TYPE OF PERMIT (Check only one. See instructions for specific information):

[ ] Non-commercial fishing or [ ] Recreational charter fishing

2.* [ ] New permit or [ ] Renewal

3.*MONUMENT PERMIT AREA (Check only one. See Instructions for specific additional information):

[ ] Marianas Trench (Islands Unit Only) [ ] Pacific Remote Islands [ ] Rose Atoll

4.*VESSEL NAME: _________________________________ 5.*VESSEL REGISTERED LENGTH: ________ (feet)

6.*VESSEL OFFICIAL NUMBER: ________________________ 7.* RADIO CALL SIGN: ____________________

USCG documentation or vessel registration number

8.*VESSEL OWNER:_______________________________________________________________________________

First, Middle, & Last Name(s), or Business Name

9.*SSN or TIN: ____________________________________________________________________________

10. *DATE OF BIRTH (individual) OR DATE OF INCORPORATION (business): _______________________

12. *MAILING ADDRESS: ______________________________________ ______________ ________ ___________

Street or P.O. Box City State ZIP code

13.* PHONE: ( ) ____________; CELL PHONE: ( ) _____________; FAX: ( ) ______________

EMAIL: __________________________________________________________

14.* VESSEL OPERATOR(S):

1. Name: ___________________________________________________ Phone:___________________________

Mailing Address: _____________________________________________________________________________

2. Name: ___________________________________________________ Phone:___________________________

Mailing Address: _____________________________________________________________________________

15.*APPLICANT: _____________________________________________________________ _________________

Printed Name and Signature of Person Submitting Application Date

16. *APPLICANT TITLE: [ ] Vessel Owner, [ ] Corporate officer or partner, [ ] Designated agent, [ ] Other________

OTHER REQUIRED DOCUMENTS:

1. Copy of the vessel’s current U.S. Coast Guard Certificate of Documentation (documented vessel), or registration certificate from a state or territorial agency (undocumented vessel) showing the current vessel owner.

2. Payment by check for the non-refundable applications processing fee of $[INSERT DOLLAR AMOUNT], payable to the Department of Commerce, NOAA.

3. Proof of residency or location of business (copy of driver’s license, identification, check, business registration, certificate of good standing, or other document verifying local address), and

4. A signed letter from the permit holder authorizing the applicant as the agent, if the applicant is acting as an agent for the vessel owner.

Filing false information on any application for a fishing permit is prohibited (50 CFR 665.15(b), 18 U.S.C. 1001). You must inform PIRO within 15 days of any change of information on the application form (50 CFR 665.13).

Privacy Act Statement: Federal regulations at (50 CFR Part 665) authorize the collection of this information. This information is used to verify the identity of the applicant(s) and to accurately retrieve confidential records related to federal fishing permits. The primary purpose for requesting the SSN or TIN is for the collection and reporting on any delinquent amounts arising of such person’s relationship with the government pursuant to the Debt Collection Improvement Act of 1966 (Public Law 104-134). Business information may be disclosed to the public.

PAPERWORK REDUCTION ACT INFORMATION

Public reporting burden for this collection is estimated at 15 minutes per application, including 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 aspects of this collection of information, including suggestions for reducing this burden, to Pacific Islands Regional Administrator, NOAA Fisheries Service, 1601 Kapiolani Blvd. Suite 1110, Honolulu, Hawaii 96814-4700.

This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal regulations in the Pacific Islands Region. This will enable NOAA Fisheries Service and the Western Pacific Fishery Management Council to (a) determine who would be affected by changes in management; (b) inform license holders of changes in fishery regulations; and (c) determine whether the objectives of the fishery program are being achieved by monitoring entry and exit patterns and other aspects of the fisheries. The information is used in analyzing and evaluating the potential impacts of regulatory changes on persons in the regulated fisheries as well as in related fisheries.

Responses to the collection are required to obtain the benefit of a permit for the fishery involved (ref. 50 CFR 665.13). Data provided concerning the proprietary business of the respondents are handled as confidential under the Magnuson-Stevens Fishery Conservation and Management Act (Sec. 402(b)), and NOAA Administrative Order 216-100. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.

Instructions

1. TYPE OF PERMIT: Please check the appropriate box for the type of permit you are applying. Non-commercial fishing means fishing that includes, but is not limited to, sustenance, subsistence, traditional indigenous, and recreational fishing. Recreational charter fishing means operating or fishing from a vessel carrying a passenger for hire who is engaged in recreational fishing. Only check one box.

2. NEW APPLICATION OR RENEWAL: Check only one box.

3. MONUMENT PERMIT AREA: Please check the appropriate Monument Permit Area you are applying. Only check one box. If you are seeking to fish in more than one Monument Permit Area, you must apply separately for each area.

Additional Specific Information:

• NMFS may issue fishing permits for the Rose Atoll Marine National Monument only to community residents of, and businesses legally established in, American Samoa.

• NMFS may issue fishing permits for the Islands Unit of the Marianas Trench Marine National Monument only to community residents of Guam and the Northern Mariana Islands, and businesses legally established in those islands.

• You are required to obtain all other applicable federal permit(s) for fishing within the Marianas Trench Marine National Monument outside of the Islands Unit. See http://www.fpir.noaa.gov/SFD/SFD_permits_index.html for a list of applicable federal permits for fishing in the EEZ around Guam and the Northern Mariana Islands.

• For the Pacific Remote Islands Marine National Monument, use this application only if you own or operate a vessel that will engage in recreational charter fishing activities. If your fishing will not involve recreational charter fishing, you must obtain the applicable federal fishing permit(s) for the Pacific Remote Islands Marine National Monument. See http://www.fpir.noaa.gov/SFD/SFD_permits_index.html for a list of applicable federal permits for fishing in the EEZ around the Pacific Remote Island Areas.

4. VESSEL NAME: Write in the vessel name.

5. VESSEL REGISTERED LENGTH: Write in the vessel’s length overall in feet, as listed on the U.S Coast Guard document or state/territorial agency vessel registration.

6. VESSEL OFFICIAL NUMBER: Write in either the U.S. Coast Guard documentation number, or state/territorial agency vessel registration number.

7. RADIO CALL SIGN: If you have one, write in the call sign assigned by the FCC to your vessel’s radio. It would probably start with a W. If you do not have a call sign, write N/A.

8. VESSEL OWNER: Write in the First, Middle, & Last Names, or Business Name of the vessel’s registered owner as listed on the U.S Coast Guard document or state/territorial agency vessel registration.

9. SSN or TIN: Write in the social security number (SSN) of the vessel owner. If the applicant is a business, write in the Taxpayer Identification Number (TIN) or Employer Identification Number (EIN) obtained from the U.S. Internal Revenue Service.

10. DATE OF BIRTH OR DATE OF INCORPORATION: If an individual owns the vessel, write in the vessel owner’s full birth date. If a business owns the vessel, write in the full date of incorporation.

11. MAILING ADDRESS: Write in the vessel owner’s primary mailing address. NMFS will use this address as the official address of record for all mail to the permit holder.

12. PHONE: Write in the vessel owner’s primary phone number.

13. CELL PHONE, FAX & EMAIL: Please provide additional contact information for the vessel owner.

14. VESSEL OPERATOR: Write in the First, Middle, & Last Names, and provide contact information for each individual that will operate the vessel while in the Monument Permit Area, if not the registered owner. Each vessel operator, if not the same as vessel owner, is required to obtain a Monument permit.

15. APPLICANT: Print your name and sign on the line. The applicant must sign the form. Then, fill in the date the application was signed

16. APPLICANT TITLE: Check only one for the applicant’s relationship to the vessel owner.