Pacific Islands Crustacean Application

OMB Control No: 0648-0586
Expires: 8/31/2018

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

PACIFIC ISLANDS CRUSTACEAN PERMIT
Please print legibly. Items marked with * are required. Note required documents and instructions on page 2.
*PERMIT TYPE:

___ Lobster (No Fee)
___ Deepwater Shrimp ($48.00 non-refundable application processing fee for shrimp permit only)

*PERMIT AREA:

___ 2. Main Hawaiian Islands
(Limited Entry permit required for Lobster in Permit Area 1 is no longer being issued.)

___ 3. American Samoa
___ 4. Pacific Remote Island Areas
___ 5. Guam and Northern Mariana Islands

*VESSEL NAME: ____________________________________________________
*VESSEL LENGTH: _______________ (feet)

*VESSEL OFFICIAL NO: ______________________
USCG or state registration number

RADIO CALL SIGN: ______________________

*VESSEL OWNER: ________________________________________________________________________
First, Middle, & Last Name or Business Name

___________________________
*Taxpayer ID Number (EIN or SSN)

*DATE OF BIRTH (Individual) OR INCORPORATION (Business): _______________________________ (MM/DD/YYYY)
*BUSINESS CONTACT: ____________________________________________________________ *TITLE: ______________________________
First, Middle, & Last Name, if not same as vessel owner

Corporate officer, business owner, partner

*BUSINESS MAILING ADDRESS: ________________________________________________ __________________ _____ ______________
Street/PO Box

City

State

ZIP Code

*BUSINESS PHONE (______) ____________________ CELL PHONE (______) ____________________
EMAIL: __________________________________________________________
Under penalty of perjury, I hereby declare that I, the undersigned, am the vessel owner or authorized to complete and certify this application on behalf of
the vessel owner, and the information contained herein is true, correct, and complete to the best of my knowledge.

*APPLICANT: ___________________________________ __________________________________________ *DATE: ____________________
Printed Name of Person Submitting Application

Signature of Applicant

*APPLICANT TITLE: ___ Vessel owner, ___ Corporate officer or partner, ___ Designated agent**, or ___ Other ____________________________
(Check only one)

*Application is for a new permit? ___ or a renewal? ___ Previous permit number if renewal: _______________________________

Rev. 12/4/17

(page 2)

OMB Control No: 0648-0586
Expires: 8/31/2018

INSTRUCTIONS FOR APPLICATION:
Please print all information legibly. Illegible writing may cause delays or errors in permit processing.
Permit Type: Check which permit you are applying for. You may apply for both permits with one application form, but remember to provide the fee
payment for the deepwater shrimp permit. Separate permits will be issued for lobster and shrimp.
Permit Area: Check the area where you will be fishing. You may check more than one if you will be fishing other areas.
Vessel Name: Write the vessel name that is marked on the vessel and/or listed on the US Coast Guard (USCG) certificate of documentation or
state/territory vessel registration form. If vessel is undocumented and has no name, please write N/A or None.
Vessel Official No.: Write the vessel’s USCG documented number or state/territory undocumented vessel registration number.
Vessel Length: Write the length overall as documented by the USCG or state/territory registration.
Radio Call Sign: Write the call sign registered with the FCC if available.
Vessel Owner: Write the official vessel owner as documented by the USCG or state/territory registration
Taxpayer ID Number: For individuals, this is your Social Security Number (SSN); for businesses, this is the Employer Identification Number (EIN).
Date of Birth or Incorporation: Write the date of birth for individuals, or date of incorporation for businesses.
Contact Person, Business Address, Business Phone and other contact information: Write the contact person name, contact person title,
vessel owner’s mailing address, and vessel owner’s telephone number. These will be the address and phone number of record. In addition, please
provide the cell phone number, fax number, and email.
Applicant and Date: The vessel owner (if individual), officer or member of the business or corporation, or designated agent must print his/her name
and write their signature. Write the full date (MM/DD/YYYY) when the application is signed.
Applicant Title: Check the role of the applicant. If the applicant is not the vessel owner or an authorized representative of the business owner of the
vessel, then a written, signed, and dated letter of authorization from the vessel owner naming the applicant as a designated agent is required.
REQUIRED DOCUMENTS: You must submit the following with the application form.
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 the current vessel owner,
2) Payment for the non-refundable application processing fee for the shrimp permit only, make check payable to Department of Commerce, NOAA.
Write the name of the vessel and the permit type in the memo or note field on the check.
3) **A signed letter from the vessel owner authorizing the applicant as the agent, if the applicant is acting as an agent for the vessel owner.
Mail application to the address at the upper left of page 1 or deliver it to NMFS Honolulu Service Center at Pier 38. An application that is lacking
required information, vessel registration or documentation, or payment will be considered incomplete. An incomplete application will be abandoned if
it is not completed within 30 days after reception. 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 any application for a fishing permit (50 CFR 665.15(b)).

OMB Control No: 0648-0586
Expires: 8/31/2018

PRIVACY ACT STATEMENT
Authority: The collection of this information is authorized under the Magnuson-Stevens Fishery Conservation and Management Act, 16 U.S.C 1801
et seq., the Western and Central Pacific Fisheries Convention Implementation Act (WCPFCIA; 16 U.S.C. 6901 et seq), the Marine Mammal
Protection Act, and the Endangered Species Act. The authority for the mandatory collection of the Tax Identification Number (TIN) is 31 U.S.C.
7701.
Purpose: In order to manage U.S. fisheries, the NOAA National Marine Fisheries Service (NMFS) requires the use of permits or registrations by
participants in the United States. Information on NOAA Fisheries permit applicants and renewing holders includes vessel owner contact information,
date of birth, TIN and vessel descriptive information. Permit holder information may be used as sampling frames for surveys.
Routine Uses: The Department will use this information to determine permit eligibility and to identify fishery participants. Disclosure of this
information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared within NMFS offices, in order to coordinate monitoring
and management of sustainability of fisheries and protected resources, as well as with the applicable State or Regional Marine Fisheries
Commissions and International Organizations. Disclosure of this information is also subject to all of the published routine uses as identified in the
Privacy Act System of Records Notice COMMERCE/NOAA-19, Permits and Registrations for the United States Federally Regulated Fisheries.
Disclosure: Furnishing this information is voluntary; however, failure to provide complete and accurate information will prevent the determination of
eligibility for a permit.
PAPERWORK REDUCTION ACT INFORMATION
Public reporting burden for this collection is estimated as follows: 15 minutes for the WP crustaceans permit application and 2 hours for all permit
denial appeals. Each burden includes 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 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 Pacific Islands 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 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 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 Number.