American Samoa Pelagic Longline Limited Access Program -

OMB NUMBER: 0648-0490

Expires: 12/31/2014

U.S. DEPARTMENT OF COMMERCE

National Oceanic and Atmospheric Administration

national marine fisheries service

Pacific Islands Regional Office - SFD Permits

1845 Wasp Blvd., Bldg 176

Honolulu, Hawaii 96818

(808) 725-5000 ∙ Fax: (808) 725-5215

AMERICAN SAMOA LONGLINE LIMITED ACCESS PERMIT

Application Type:

Please print legibly. All fields required unless noted otherwise. Provide required documents as instructed. Non-Refundable Application Processing Fee: $48.00, payable by check or money order to: Department of Commerce, NOAA. Fee charged for all permit transactions unless otherwise noted below.

PERMIT CLASS: ___ A = vessel 40’ LOA or less ___ B = 40.1’ – 50’ ___ C = 50.1’ – 70’ ___ D = 70’ or larger

___ Permit Renewal

___ Additional Permit Issuance

___ Registration of new or replacement vessel to permit OR De-registration of vessel from permit. (No Fee)

___ Permit Transfer (The transferring permit holder completes this section and signs, and the person receiving the permit completes the sections below and signs

as the permit applicant.)

TO: ___ Family member ___ Community organization ___ Person with documented participation in the American Samoa longline

fishery (participation in vessel size Class A for Class A only)

NAME: ________________________________________________________ Relationship: ______________________________

Print first and last name, or name of community organization If Family member is checked

Under penalty of perjury, I hereby declare that I, the undersigned, is authorized to complete and certify this application on behalf of the current permit holder and the information contained herein is true, correct, and complete to the best of my knowledge.

PERMIT TRANSFEROR: ____________________________________________ ________________________________________________

(Original permit holder) Print first, middle initial, and last name Signature

PERMIT NUMBER BEING TRANSFERRED: ____________________________ DATE: _____________________

VESSEL NAME: ________________________________________ VESSEL OFFICIAL NUMBER (USCG or AS): ______________________

VESSEL OWNER: __________________________________________________________ RADIO CALL SIGN: _________________________

PERMIT HOLDER: ________________________________________________________ TAXPAYER ID NUMBER: ________________________

First, Middle and Last Name, or Business Name (SSN or EIN)

PERMIT HOLDER DATE OF BIRTH (individual) or INCORPORATION (business):

Complete the Supplementary Information Sheet on page 2 to list names and addresses of owners, partners, or officers.

BUSINESS MAIL ADDRESS: ______________________________________________ _________________________ _____ ________

Number, street, apt. no. City/Village State ZIP

BUSINESS PHONE: (______) _______________________ CELL: (_____) _________________________

(Please include the area code for each number)

EMAIL: _________________________________________________________________________

Under penalty of perjury, I hereby declare that I, the undersigned, is authorized to complete and certify this application on behalf of the applicant and the information contained herein is true, correct, and complete to the best of my knowledge.

APPLICANT: ____________________________________________ ______________________________________DATE: ________________ Print first, middle initial, and last name Signature

Mail application to the address at the top left of this page. If your application is incomplete, you will be notified by PIRO. You have 30 days from the date of notification to complete the application or your application will be considered abandoned (50 CFR 665.13). You must inform PIRO within 15 days of any change of information on the application form (50 CFR 665.13). It is prohibited to file false information on an application for a fishing permit (50 CFR 665.15(b)).

Privacy Act Statement: Federal Regulations (at 50 CFR Part 665) authorize 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 permits. The primary purpose for requesting the Taxpayer ID Number (SSN or EIN) is for the collection and reporting on any delinquent amounts arising out of such person’s relationship to 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.

OMB Control No. 0648-0490

Expiration Date: 12/31/2014

(page two)

American Samoa Pelagic Longline Access Entry Permit

SUPPLEMENTARY INFORMATION SHEET

Company/Corporation officers, owners, or partners:

NAME MAILING ADDRESS PERCENT OWNERSHIP

For office use only:

___ Previous ownership of longline vessel: Vessel Name: ___________________________________

USCG COD ______________ or AS Vsl Reg. _________________

___ Vessel used to legally harvest Pacific pelagic management unit species with longline gear in the EEZ around

American Samoa.

___ Fulfilled minimum harvest requirements for renewal

___ Current Protected Species Workshop certification (for renewal)

___ Certification of Limited Access Permit Transfer if applying for a transfer

___ Documented ownership or evidence of work (Participation) on an AS longline fishing vessel:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PAPERWORK REDUCTION ACT INFORMATION

Public reporting burden for this collection is estimated as follows: 45 minutes for American Samoa longline limited access initial permit issuance, renewal, transfer or upgrade; 2 hours for permit appeal. Send comments regarding this burden estimate and any other aspects of this collection of information, including suggestions for reducing this burden, to NMFS Pacific Islands Regional Administrator, 1845 Wasp Blvd., Bldg. 176, Honolulu, HI 96818.

This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal regulations in the Western Pacific Region. This will enable NMFS 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 regulatory changes on person in the regulated fisheries as well as in related fisheries. Responses to the collection are required to obtain the benefit of a license for the fishery involved (ref. 50 CFR 665.13). Data provided concerning the vessel and/or business of the respondents are handled as confidential under the Magnuson-Stevens Fishery Conservation and Management Act (Sec. 402 (b)). 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 Numbers.

OMB Control No. 0648-0490

Expires: 12/31/2014

(page three)

Instructions for American Samoa Pelagic Longline Limited Access Permit Application

Application Type: Check which type of permit action you are applying for. Please submit a separate form for each permit. Only application for renewal, an additional permit, or vessel registration/replacement is allowed. A non-refundable application processing fee of $48.00 is required for an application for Renewal, Additional Permit, or Transfer.

For Permit Transfer: This section must be completed by the current permit holder(s) who is transferring the permit (transferor) to another person or business (transferee). They must write their name, their signature, and date it. The permit number being transferred must be provided. NMFS may request additional documentation to verify the transfer.

Vessel Information: Fill in the vessel name, official number (either USCG documented vessel number or state registered number for undocumented vessels), vessel owner name, and radio call sign. If the vessel has no name, please draw a line in the vessel name field.

Permit Holder Information: Fill in the name of the person or business to whom the permit will be issued. This entity will be the permit holder for the duration of the permit. Provide the taxpayer ID number: SSN for individual, or EIN (employer identification number) for a business. Fill in the date of birth of the individual or the date of incorporation for the business. If there is more than one permit holder, provide the same information for each permit holder. Any change in the name of the permit holder(s) will require a transfer.

Provide the mailing address, phone numbers, and email of the permit holder. This will be the address of record.

Permit Applicant: The person who submits the application must print his or her name and sign the form. Fill in the application date, and the applicant’s title. If the applicant is not the permit holder or is not a member or officer of the business that holds the permit, the permit holder must provide a signed letter of authorization that designates the applicant as the agent.

Supplementary Information Sheet: If the permit holder is a business or partnership, list all owners, partners, and officers of the company on this sheet. Provide addresses and percent ownership for each.

Required Documents to provide with the application:

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

2) Payment for the non-refundable application processing fee, if required,

3) Documentation of harvest for Renewal,

4) Documentation of participation in the American Samoa longline fishery if applying for an Additional Permit or Permit Transfer,

5) For Transfers: A signed and notarized Certification of Limited Access Permit Transfer from the original permit holder confirming the transfer of an American Samoa longline limited access permit, and

6) A signed letter from the permit holder authorizing the permit applicant as the agent, if the applicant is not the permit holder.

The vessel owner must have a current Protected Species Workshop (PSW) to renew the permit. If the vessel owner is a business, an officer or authorized representative of the company must have a current PSW certificate. Contact piropsw@noaa.gov for workshop information.

If your application is incomplete, you will be notified by PIRO. You have 30 days from the date of notification to provide required documents, or your application will be considered abandoned (50 CFR 665.13). You must inform PIRO within 15 days of any change of information on the application form (50 CFR 665.13). It is prohibited to file false information on an application for a fishing permit (50 CFR 665.15(b)).

Submit Complete Application to: the address printed in the upper left corner of the first page, or contact the Permits Program at

piro-permits@noaa.gov for information on online renewals of American Samoa longline permits, and other permits as available.

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