Form 3-200-90 Federal Fish and Wildlife Permit Application Form - Spec

FWS Form 3-200-90 (Rev. 10/2020) OMB Control No. 1018-0175

U.S. Department of the Interior Expires ##/##/####

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

Special Double-Crested Cormorant

(Migratory Bird Treaty Act; 50 CFR 21.28)

U.S. Fish and Wildlife Service

Division of Migratory Bird Management

TYPE OF REQUEST

New Application

Renewal

Amendment

If requesting a renewal or amendment, please provide the permit #: _____________________

BEFORE FILLING OUT THIS FORM, please access the Return Addresses (to obtain the email/postal mail addresses where this form can be returned), and read the form Frequently Asked Questions and instructions on page 6 of this form. Please retain the "NOTICES" page for your records.

NOTE: A Federal Special Double-Crested Cormorant permit is available only to a State or Tribal fish and wildlife management agency responsible for migratory bird management on lands and waters under their jurisdiction. Anyone conducting activities under authority of this permit must be listed as a subpermittee. Subpermittees must be at least 18 years old. Nonlethal methods to resolve conflicts must be attempted before lethal take occurs.

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details. See instructions on last page for information on how to make your application complete and help avoid unnecessary delays.

A. Complete if applying as an individual
1.a. Last name		1.b. First name	1.c. Middle name or initial	1.d. Suffix
2. Date of birth (mm/dd/yyyy)	3.a. Telephone number	3.b. Alternate telephone number	3.d. E-mail address

B. Complete if applying on behalf of a State agency or Tribe
1.a. Name of Agency or Tribe
4.a. Principal Officer Last Name		4.b. Principal Officer First Name			4.c. Principal Officer Middle Name/Initial	4.d. Suffix
5. Principal Officer Title				6. Primary Contact Name
7.a. Business Telephone Number	7.b. Alternate Telephone Number		7.c. Business Fax Number		7.d. Business E-mail Address

C. All applicants complete address information
1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
1.b. City	1.c. State	1.d. Zip code/Postal code:	1.e. County/Province	1.f. Country
2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City	2.c. State	2.d. Zip code/Postal code:	2.e. County/Province	2.f. Country

D. All applicants MUST complete

1. Processing fees – none required. Tribal and State agencies, and those acting on behalf of such agencies, are exempt from the processing fee (50 CFR 13.11(d)(3)(i).

2. Do you currently have or have you ever had any Federal Fish and Wildlife permits?

Yes No If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: ___________________

^3. Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and the other applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit is complete and accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001.

__________________________________________________________________________________ __________________________

Signature of applicant/Principal Officer (No stamped signatures. Electronic signatures accepted.) Date of signature (mm/dd/yyyy)

Please continue to next page

SECTION E

Please provide the information requested below. We may request additional information as appropriate to the activities you are requesting (50 CFR 13.21(d)). You should be as thorough and specific as possible in your responses. Incomplete applications will be returned. If additional space is required, add additional sheets to your application submission. You may use as many additional sheets as needed. Please number pages accordingly using the page number box provided at the bottom of the sheet, and the corresponding question number.

If you are requesting renewal, all required reporting must be up to date or the renewal will not be processed. The report form can be found at https://www.fws.gov/forms/3-202-56.pdf. If you are requesting renewal, you still need to complete the entire application and provide all the requested information.

1. Describe the history of double-crested cormorant conflicts in your state or tribal lands. Include locations(s) that are historically areas for conflict and, for each location, the type of conflict experienced (aquaculture/hatchery, human health and safety, property damage, t/e species protection, and/or wild and stocked fish). As appropriate, include the size/description of the area affected, how long this conflict has been occurring, what time of year the conflict occurs, and what time of year you will be conducting management activities, visit https:// earthexplorer.usgs.gov/

2. For each location(s), describe the non-lethal methods that you have used previously and/or plan on implementing, including (a) active hazing (e.g. horns, pyrotechnics, propane cannons, etc.), (b) passive deterrents (e.g. netting, exclusion devices, nest deterrents, etc.), (c) habitat management (e.g. vegetative barriers, grass management, prey management, etc.), and (d) practice changes (e.g. water level management, fish release timing, etc.).

3. Describe your proposed double-crested cormorant management activities, including the number of double-crested cormorants you propose to take by life-stage (i.e. adults, active nests, etc.) and the method you propose to use (i.e. shooting, nest-destroy, egg-oiling, etc.).

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4. Describe your long-term plans to eliminate or significantly reduce the continued killing of double-crested cormorants or destruction of eggs/nests.

5. The name and telephone number of the individual in your agency who will be in charge of the double-crested cormorant management activities authorized under your permit.

6. Subpermittees: Anyone who will be assisting you with the permitted activities or acting as your agent must either have their own Federal migratory bird permit for the activity or be identified by you, in writing, as a subpermittee under your permit. Subpermittees must be at least 18 years old. As the primary permittee, you will be responsible for ensuring that your subpermittees are properly trained and adhere to the terms of your permit. Provide the name of any subpermittees who will be conducting activities under your permit. Include the name and contact information of any commercial company that may be contracted to conduct the work.

7. By requesting this permit, I acknowledge that, if a permit is issued, the State/Tribe will be responsible for the following:

(a) A record keeping system for tracking take that includes: the specific location (GPS coordinates in decimal degrees), the county, a description of the non-lethal methods implemented and their general efficacy for resolving the conflict, the number of double-crested cormorants and, if applicable, non-target species taken, the method of take, and the purpose of take relevant to the type of conflict (aquaculture, health, t/e, property, stocked fish). Take data must be current, sufficient to ensure tracking within authorized take limits and update at least every 30 days.

(b) Activities that fall outside the scope of this permit require a separate Depredation permit. Activities may not occur under both a Depredation permit and this permit.

(c) An outreach plan for communicating with the public the activities occurring under this permit, including the implementation non-lethal methods.

(d) The Principal Officer is responsible for ensuring all subpermittees (employees and contractors) are fully informed and briefed regarding the regulatory requirements and conditions of this permit.

(e) Anyone taking birds under this permit must be skilled in double-crested cormorant identification. Non-target take of any other avian species must be reported to your permit office with your annual report including species, number, and description of events.

8. You must retain records legibly written or reproducible in English relating to the activities conducted under your permit for at least 5 years after the date of expiration of your permit. Is the physical address you provided in Section C on page 1 of this application the address where your records will be kept? Yes No If “no,” provide the physical address:

9. I acknowledge that I have read the form Instructions and Frequently Asked Questions, and have accessed the page with the Return Addresses to obtain the address where I should return this form. I have also filled out all fields and questions in this application. Check this box to acknowledge.

NOTICES

PRIVACY ACT STATEMENT

Authority: The information requested is authorized by the following: the Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22; the Endangered Species Act (16 U.S.C. 1531-1544), 50 CFR 17; the Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR

21; the Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15; the Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16; Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), 50 CFR 23; General Provisions, 50 CFR 10; General Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 50 CFR 14.

Purpose: The collection of contact information is to verify the individual has an eligible permit to conduct activities that affect protected species. The information the individual provides helps the FWS monitor and report on protected species and assess the impact of permitted activities on the conservation and management of species and their habitats.

Routine Uses: The collected information may be used to verify an applicant’s eligibility for a permit to conduct activities with protected wildlife; to provide the public and the permittees with permit related information; to monitor activities under a permit; to analyze data and produce reports to monitor the use of protected wildlife; to assess the impact of permitted activities on the conservation and management of protected species and their habitats; and to evaluate the effectiveness of the permit programs. More information about routine uses can be found in the System of Records Notice, Permits System, FWS-21.

Disclosure: The information requested in this form is voluntary. However, submission of requested information is required to process applications for permits authorized under the listed authorities. Failure to provide the requested information may be sufficient cause for the U.S. Fish & Wildlife Service to deny the request.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary to monitor take and disposition of migratory birds, under the applicable laws governing the requested activity, for which a permit is requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request. 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 collection of information and assigned Control No. 1018-0175.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information averages:

Original submission - paper-based: 16 hours

Amended submission - paper-based: 4 hours

Original submission - electronic: 14 hours

Amended submission - electronic: 3 hours

These estimates include time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at Info_Coll@fws.gov. Please do not send your completed form to this address.

FREEDOM OF INFORMATION ACT STATEMENT

For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under Freedom of Information Act (FOIA). Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The non- confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

PERMIT APPLICATION FORM INSTRUCTIONS

The following instructions pertain to an application for a U.S. Fish and Wildlife Service permit. The General Permit Procedures in 50 CFR 13 address the permitting process. For simplicity, all licenses, permits, registrations, and certificates are referred to as a permit.

GENERAL INSTRUCTIONS:

• Complete all blocks/lines/questions in Sections B, C, D, and E.

• An incomplete application may cause delays in processing or may be returned to the applicant. Be sure you are filling in the appropriate application form for the proposed activity.

• Print clearly or type in the information. Illegible applications may cause delays.

• Sign the application. Faxes or copies of the original signature will not be accepted.

• Mail the original application to the address at the top of page one of the application or if applicable on the attached address list.

• Keep a copy of your completed application.

• Please plan ahead. Allow at least 60 days for your application to be processed. Some applications may take longer than 90 days to process. (50 CFR 13.11)

• Applications are processed in the order they are received.

• Additional forms and instructions are available from https://www.fws.gov/birds/policies-and-regulations/permits.php

ALL APPLICANTS SKIP SECTION A AND COMPLETE SECTION B:

This permit is not available to individuals.

Section B. Complete if applying as a State agency or Tribe:

• Enter the complete name of the State or Tribal wildlife agency. Provide contact phone number(s) for the agency.

• Principal Officer is the person responsible for the State or Tribal agency's application and any permitted activities. Often the principal officer is a State Director or Tribal Natural Resources Director. Primary Contact is the person at the business, corporation, public agency, Tribe, or institution who will be available to answer questions about the application or permitted activities. Often this is the preparer of the application.

ALL APPLICANTS COMPLETE SECTION C:

• For all applications submitted, a physical U.S. address is required.

• Mailing address is address where communications from USFWS should be mailed if different than applicant’s physical address.

ALL APPLICANTS COMPLETE SECTION D:

Section D.1 Application processing fee:

• An application processing fee is not required at the time of application because State and Tribal wildlife agencies are exempted under 50 CFR13.11(d)(3)(i).

• Documentation of fee exempt status is not required for Federal, Tribal, State, or local government agencies.

Section D.2 Federal Fish and Wildlife permits:

• List the number(s) of your most current FWS permit or the number of the most recent permit if none are currently valid.

Section D.3 CERTIFICATION:

• The Principal Officer named in Section B must sign and date the application. This signature binds the applicant to the statement of certification. This means that you certify that you have read and understand the regulations that apply to the permit. You also certify that everything included in the application is true to the best of your knowledge. Be sure to read the statement and re-read the application and your answers before signing.

ALL APPLICANTS COMPLETE SECTION E.

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