3-2321 Application-Nomination Form

FWS Form 3-2321 (Rev. 05/2018)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0075
Expires ##/##/2022

APPLICATION/NOMINATION FORM
Federal Subsistence Regional Advisory Council Membership

APPLICANT’S FULL NAME:
MR./MRS.:_______________________________________________________
FIRST
Full mailing address:

MIDDLE

LAST

_

Contact Information:
Home: (907)
Work: (907)
Fax: (907)
E-mail:
Birthdate:

Where is your (or your nominee’s) primary place of residence? (Please note that members must
reside in the region they represent.)
PLEASE ANSWER THE FOLLOWING QUESTIONS (ATTACH ADDITIONAL PAGES IF NEEDED):
1) Describe your (or nominee's) knowledge of fish and wildlife resources in the region.

2) Describe your (or nominee's) knowledge of customary and traditional uses of resources in the
region.

3) Describe your (or nominee's) knowledge of sport, guided sport, commercial, and other uses of
fish and wildlife resources in the region.

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FWS Form 3-2321 (Rev. 05/2018)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0075
Expires ##/##/2022

4) Do you (or nominee) participate in meetings on fish and wildlife issues (for example, meetings of
State fish and game advisory committees, Federal subsistence regional advisory councils, commercial or
sport hunting or fishing organizations, marine mammal commissions, tribal or corporation resource use
groups, caribou working groups, subsistence resource commissions, coastal resource service areas,
waterfowl conservation committees)? If so, please describe your (or nominee's) involvement.

5) Have you (or nominee) served in an official capacity on councils, boards, committees, or
associations within the past 10 years? If yes, please describe the role you served while working
with these groups (i.e. Chair, Vice Chair, member).

6) The seat you are applying for represents users throughout the region. How would you (or
nominee) find out about fish and wildlife concerns people have and get information back to those
people?

7) Do you (or nominee) use Federal lands for hunting, trapping, fishing, guiding or
transporting, gathering, teaching of traditional knowledge, or other use of fish and wildlife
resources? If yes, please describe which Federal lands you use.

8) Will you (or nominee) travel to and attend Regional Advisory Council meetings at least two
times each year? (Regional Advisory Council meetings are usually held in August-October for fall
meetings and and February-March for winter meetings. Transportation and lodging are prepaid; per diem
is provided for food and other expenses.)

Yes____

No____

9) Are you (or nominee) willing to attend Federal Subsistence Board meetings
occasionally? (Board meetings are usually held in January or April. Transportation and lodging
are prepaid; per diem is provided for food and other expenses.)
Yes____

No____
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FWS Form 3-2321 (Rev. 05/2018)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0075
Expires ##/##/2022

10) Regional Advisory Council membership should reflect representation of subsistence and
commercial/sport interests. Regional Advisory Council seats are designated for either subsistence use
or commercial/sport representatives. You (or nominee) must choose one or the other.
____ subsistence

____ commercial/sport

If you are nominating the applicant, please provide your name, your title, and your
organization.

Your Name and Title

Organization

Reference Contacts: Please include three references and their contact information. Please provide the
most current phone numbers available. If you wish, you may also submit letter(s) of recommendation.

Name:
Organization:
Address:
Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Name:
Organization:
Address:

Name:
Organization:
Address:

I certify, to the best of my knowledge, that all statements are correct and complete.
Signature

Date

Please note: All applications must be signed in ink. No application or nomination will
be considered complete without a signature.

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FWS Form 3-2321 (Rev. 05/2018)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0075
Expires ##/##/2022

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the Alaska National Interest Lands Conservation Act; 36 CFR
242 and 50 CFR 100.
Purpose: The applicant’s information will be used to evaluate their qualifications and experience for the potential
selection to serve as a member on one of the Federal Subsistence Regional Advisory Councils.
Routine Uses: The Federal Subsistence Board will use the provided information to make recommendations to the
Secretaries of Interior and Agriculture for the appointment of members to the Federal Subsistence Regional Advisory
Councils. More information about routine uses can be found in the System of Records Notice, Permits System,
FWS-21.
Disclosure: Providing the information is voluntary, but required to obtain or retain a benefit.
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 make recommendations to the Secretaries of the Interior and Agriculture for appointment of
members to the Federal Subsistence Regional Advisory Councils. It is our policy not to use your name for any other
purpose. Your response is voluntary, but is required to obtain or retain a benefit. 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. 1018-0075.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 2 hours 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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