EM Provider Permit Application & Renewal Form

ELECTRONIC MONITORING PROVIDER PERMIT APPLICATION AND RENEWAL FORM PACIFIC COAST GROUNDFISH FISHERY

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, West Coast Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 http://www.westcoast.fisheries.noaa.gov/

OMB Control No. 0648-XXXX; Expires: DATE

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to obtain an electronic monitoring (EM) service provider permit. For EM service providers wishing to renew an existing permit, a pre-filled version of this form is available by contacting NMFS at the telephone number above.
Section A – Applicant Information
1. Legal Name of Applicant			2. TIN (if business) or DOB (if person)
			3. State Registered In (if business)
4. Business Mailing Address Street or PO Box			5. Business Phone Number ( )
			6. Business Fax Number (optional) ( )
City	State	Zip Code	7. Business Email (optional)

Section B – List of Owners, Board Members, Officers, Authorized Agents and Employees
List Names of All Current Owners, Board Members, Officers, Authorized Agents and Employees
Name	Date of Birth	Role in Applicant Organization O = Owner; BM = Board Member; OF = Officer AA=Authorized Agent and E = Employee
Section B – List of Owners, Board Members, Officers, Authorized Agents and Employees
Name	Date of Birth	Role in Applicant Organization O = Owner; BM = Board Member; OF = Officer AA=Authorized Agent and E = Employee
If you need to list additional persons, please make a copy of this page and type “Continued” at top and append to application.

Section C – Supplemental Information

Please append documents providing the following information to the application form.

1. Describe the management and structure of the applicant organization. At a minimum, such description should provide the general functional responsibilities of various staff, all office locations and their business addresses, business phone number, fax number and email addresses. Also, if a corporation attach articles of incorporation or if a partnership, attach the partnership agreement.

2. A narrative statement describing prior relevant experience in providing EM services, technical support, or fishery data analysis services, including recruiting, hiring, training, deploying, and managing of individuals in marine work environments and of individuals working with fishery data, in the groundfish fishery or other fisheries of similar scale.

3. An EM Service Plan that describes in detail how the applicant will provide EM services to the fishery sufficient to provide NMFS with the best scientific information available to determine individual accountability for catch, including discards, of IFQ species and compliance with requirements of the Shorebased IFQ Program (§ 660.140) and MS Coop Program (§ 660.150). EM Program Guidelines containing best practices for EM Service Plans are available on NMFS’s website: http://www.westcoast.fisheries.noaa.gov/fisheries/groundfish_catch_shares/electronic_monitoring.html

The EM Service Plan must include descriptions of the following (using pictures and diagrams where appropriate):

1. Contact information for a primary point of contact for program operations inseason;

2. A plan for provision of services including communications, service locations, response timelines, and procedures for services, repairs, technical support, and other program services;

3. Procedures for hiring and training of competent program staff to carryout EM field services;

4. Procedures for tracking hard drives and datasets throughout their use cycle, including procedures to ensure the integrity and security of hard drives in transit, and if end-to-end encryption is not used, procedures for removing confidential data from hard drives before returning them to the field;

5. Policies on data access, handling, and release to maintain the confidentiality of the EM Program data;

6. Identifying characteristics of the EMS to be deployed and the video review software to be used in the fishery, including but not limited to: manufacturer, brand name, model name, model number, software version and date, firmware version number and date, hardware version number and date, monitor/terminal number and date, pressure sensor model number and date, drum rotation sensor model number and date, and GPS model number and date.

7. EM system and software specifications, including a narrative statement describing how the EM system and associated equipment meets the performance standards at § 660.604(j).

8. EM video review software specifications, including a narrative statement describing how the software is sufficient to provide NMFS with the best available information to determine individual accountability for catch, including discards, of IFQ species and compliance with requirements of the Shorebased IFQ Program (§ 660.140) and MS Coop Program (§ 660.150).

4. Provide NMFS the following, if requested:

1. Two EM system units loaded with software for a minimum of 90 calendar days for testing and evaluation.

2. Thorough documentation for the EM system, including: user manuals, any necessary interfacing software, performance specifications, technical support information, and tamperproof or tamper evident features.

3. The results of at-sea trials of the EM system.

4. Two copies of video review and analysis software for a minimum of 90 calendar days for testing and evaluation.

5. Thorough documentation for the video review and analysis software, including: user manuals, performance specifications, and technical support information.

Section D – Conflict of Interest, Criminal Convictions, Negative Performance Ratings on Federal Contracts, and Decertification
Under penalty of perjury, I either Affirm or Do Not Affirm as specified below, that all owners, board members, officers, authorized agents, and employees, are free from the following:
Affirm	Do Not Affirm	Conflict of interest as described in 50 CFR § 660.18 (c)(3)
Affirm	Do Not Affirm	Criminal convictions
Affirm	Do Not Affirm	Any previous Federal contract with an unsatisfactory performance rating
Affirm	Do Not Affirm	Any previous decertification action while working as an observer provider, catch monitor provider, or EM provider
Please Note: If you cannot affirm any of these statements or are unsure, check “Do Not Affirm” and attach to the application relevant information to enable NMFS to make a decision.

Section E – Certification of Applicant
Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant and completed this form, and the information contained herein is true, correct, and complete to the best of my knowledge and belief. I also certify that the EM service provider is willing and able to comply with all applicable requirements of this section and to operate under a NMFS-accepted EM Service Plan.
Signature of Authorized Representative	Date
Printed Name of Authorized Representative

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.

PRIVACY ACT STATEMENT: All of the information collection described above is confidential under section 402(b) of the Magnuson- Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics except for the name and address of the applicant and the endorsement requested. The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United States Federally Regulated Fisheries. An amended notice was published in the Federal Register on August 7, 2015 (80 FR 47457) and became effective on September 15, 2015 (80 FR 55327).

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 10 hours per response, including the time for reviewing the 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 suggestions for reducing this burden to NOAA/National Marine Fisheries Service, West Coast Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected 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.

3