Form 3-2405 Self-Clearing Check-In/Out Permit

OMB Control No. 1018-0153
Expires XX/XX/20XX

Self-Clearing Check-In Permit

You must complete the Check-In portion of this daily permit and put it in
the permit box before engaging in any activity on the Refuge.

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U. S. Fish and Wildlife Service
(Refuge will insert refuge name)
Each user must [carry/display on dash] the Daily Visitor Registration portion
while on the Refuge. At the conclusion of your visit, complete the following
information and put this portion in the permit box.
Number of hours spent on Refuge
Hunter Harvest Information: (Please check all that apply)
(Option 1:) Did you harvest any wildlife?
How many ? - Example: Squirrel 3

Yes

No

(Option 2:) What were you hunting ? How many did you harvest ?
(Check all that apply)
(Put Zero if no game harvested)
Example: X Squirrel _3_ X Deer _0_
Game Species
(Each Refuge will list relevant species with a space for the number harvested
and other relevant data required.)
Incidental Species
(Each Refuge will list relevant incidental species and other relevant data
required.)
Method:
(Each Refuge will list allowable methods of harvest.)
Angler Harvest information:
(Each Refuge will list relevant species and other relevant data required.)
Did you observe:
(Each Refuge will list relevant species.)

--- NOTICES --Privacy Act Statement
Authority: The information requested is authorized by the National Wildlife Refuge
System Administration Act (16 U.S.C. 668dd-ee) and the Refuge Recreation Act (16
U.S.C. 460k-460k-4)
Purpose: To collect the applicant’s information to evaluate the qualifications, determine
eligibility, and document permit applicants in accordance with the Acts listed above.
Routine Uses: The information will be used by the refuge’s administrative office for
processing Commercial Activity Special Use permits. More information about the routine
uses maybe found in the Systems of Records Notice, FWS-5 National Wildlife Refuge
Special Use Permits.
Disclosure: Providing the information is voluntary. However, submission of information is
required to process and approve activity usage in the National Wildlife Refuge System.
Paperwork Reduction Act Statement
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C.
3501) to evaluate the qualifications, determine eligibility, and document permit applicants,
and to respond to requests made under the Freedom of Information Act and the Privacy
Act of 1974. This information is required in order to obtain or retain a benefit; however,
failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife
Service to deny a permit. According to the Paperwork Reduction Act of 1995, an agency
may not conduct or sponsor and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. OMB has approved
this information collection and assigned control number 1018-0153.
Estimated Burden Statement
We estimate the relevant public reporting burden for this information collection to average
5 minutes per response, 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
the Service Information Collection Clearance Officer, Division of Policy, Performance, and
Management Programs, Fish and Wildlife Service, Mail Stop BPHC, 5275 Leesburg Pike,
Falls Church, VA 22041-3803, or via email at Info_Coll@fws.gov. Please do not send
your completed form to this address.

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Self-Clearing Daily Vehicle Permit
Each user must enter the date and, while on the Refuge,
display this tag in the vehicle in clear view.

VEHICLE TAG
Other Side Face-up
FWS Form 3-2405
Rev. 06/2018

Self-Clearing Check-In Permit
U. S. Fish and Wildlife Service
(Refuge will insert refuge name here)
Daily Permit Check in Date:
Name:
Ph#:

(pre-coded) Permit #
Cel#:

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Self-Clearing Daily Visitor Registration Permit
Each user must complete the following information and
[carry this portion/display on dash] while on the Refuge.
At the conclusion of your visit, complete the information
on the reverse side and put this portion in the permit box.
Date

(pre-coded) Permit

#

Name
City

State

Zip Code
Purpose of Visit: (Please check all that apply)
Hunting
Photography

Birding

Wildlife Observation

Auto Touring

Boating/Canoeing

Fishing

Visitor Center

Environmental Education Class

Hiking
Special Event

Volunteering

Other Recreation (please specify):

_

Refuge Unit(s) Visited
Map of Refuge or Refuge Unit(s)

(Refuge will insert a map of the refuge)

Comments:

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Self-Clearing Daily Vehicle Permit
Date:

_ (pre-coded) Permit #

If there is more than one person in the vehicle,
there must be a tag for each user displayed
in the vehicle in clear view.

_