Form 3-177, 3-177a 3-177, 3-177a Declaration for Importation or Exportation of Fish or Wi

USFWS Form 3-177
USFWS
Form 3-177
(Revised
03/10)
(Revised
12/03)
O.M.B.
No. 1018-0012
O.M.B.Date:
No. 118-0012
Expiration
04/30/2016

1. Date of Import/Export: (mm/dd/yyyy)
___ ___ / ___ ___ / ___ ___ ___ ___

U.S. FISH AND WILDLIFE SERVICE
DECLARATION FOR IMPORTATION
OR EXPORTATION OF
FISH OR WILDLIFE

7. Name of Carrier:
8. Air Waybill or Bill of Lading Number:
Master:
House:

2. Import/Export License Number:
3. Indicate One: † Import
4. Port of Clearance:

†

9. Transportation Code: __________
Export

______________
License #

_______ ________

______________
State or Province

10. Bonded Location for Inspection:

5. Purpose Code: ________
6. Customs Document Number (s)

11. Number of Cartons Containing Wildlife:
12. Markings on Cartons Containing
Wildlife:

13a. (Indicate One) (Complete name/U.S. address/telephone number/e-mail address)
† U.S. Importer
† U.S. Exporter

14a. (Indicate One)
(Complete name/foreign address/telephone number/e-mail address)
† Foreign Importer
† Foreign Exporter
14b. Country Code
____ ____

Type Address Here

Type Address Here

13b. Identifier Number: __________________ ID Type: __________________
15a. Customs Broker, Shipping Agent or Freight Forwarder:
(Complete business name/address/telephone and fax number/e-mail address)

14c. Identifier Number: ____________________ ID Type: ____________________
15b. Identifier Number: __________________ ID Type: ________________

Type Address Here
15c. Contact Name: _______________________________________________
Species
Code

(Official Use
Only)

16a. Scientific Name

17a. Foreign CITES Permit
Number

18a. Description
Code

19a.
Quantity/Unit

16b. Common Name

17b. U.S. CITES
Permit Number

18b. Source
Code

19b. Total
Monetary Value

20. Country
of Species
Origin Code
(ISO Code)

21.
Venomous
Live Wildlife
Indicator ;
(Check if yes)

†
†
†
†
Knowingly making a false statement in a Declaration for Importation or Exportation of Fish or Wildlife
may subject the declarant to the penalty provided by 18 U.S.C. 1001 and 16 U.S.C. 3372(d)

22. I certify under penalty of perjury that the information furnished
is true and correct:

For Official Use Only

_______________________________ ____________

Action/Comments:

Signature

Date

______________________________________________________
Type or Print Name

Wildlife Declared:

Yes

Wildlife Inspected:
None / Partial / Full

No

See Reverse Side of this Form for Privacy Act Notice