Form 3-200-43d Application - Letter of Authorization for Marine Mammals

OMB Control No. 1018-0093
Expires xx/xx/xxxx

FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

LETTER OF AUTHORIZATION FOR MARINE MAMMAL
RESCUE/REHABILITATION PURPOSES (MMPA/ESA)
☐New

☐Reissue/Renew ☐Amendment

APPLICATION FORM INSTRUCTIONS
The following instructions pertain to U.S. Fish and Wildlife Service (FWS) permit applications. 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.
If you are an individual, who would be named on the face of the permit, you need to complete the Individual Applicant section of this
application.
If you are an individual seeking permits issued to yourself for activities not associated to your business or institution, you need to
complete the Individual Applicant section as an individual permittee.
If you are an individual associated with a business or institution, and the business or institution’s name would appear on the face of the
permit, you need to complete the Business Applicant section of this application.
If you are a business applying on behalf of an individual, you need to complete the Business Applicant section of this application and
include a limited power of attorney from the person for whom you represent.
A person/entity is qualified to obtain a U.S. Fish and Wildlife Service permit or license when they are "subject to the jurisdiction of the
United States", per 16 USC 1532(13). A foreign person/entity with no permanent physical presence in the United States only qualifies
for an import/export license when they physically enter or exit the U.S. with the wildlife items. The foreign entity is required to designate
a U.S. agent for purposes of record keeping.
GENERAL INSTRUCTIONS:
•

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. Items marked with an asterisk (*) are required fields.

•

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.

•

If mailing your submission, mail the original application to the address listed below 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, however, some applications may take longer than
90 days to process (50 CFR 13.11). Longer processing times will be noted on those applications.

•

Applications are processed in the order they are received.

Individual or Business Applicants:
Individual Applicant. Complete if applying as an individual [do not complete this application if applying for Import/Export License (3200-3) or a Designated Port Exception Permit (3-200-2)]:
•

Enter the information requested. Required fields must be completed. This is used to create your profile and consumer information
in the ePermits system. If you do not have an email address, enter not applicable.

•

Doing business as (dba) / Affiliation: The Division of Management Authority (DMA) and the Office of Law Enforcement (OLE) do
not accept doing business as affiliations for individuals seeking permits on behalf of themselves. “Doing business as” affiliations
apply to individuals seeking permits for a business, agency, Tribe, organizational, or institutional affiliation directly related to the
activity requested in the application. For example, a taxidermist is an individual whose business can directly relate to the requested
activity of exporting taxidermy (dba relevant permit); however, said taxidermist should not apply as a business for permits to nonbusiness related travel with their pet exotic parrot (dba is not relevant to the permit). (complete the Business Applicant section).

Business Applicant. Complete if applying as a business, corporation, public agency, Tribe, or institution:
•

Enter the information requested. Required fields must be completed. This is used to create your contact and account information in
the ePermits system. If you do not have an email address, enter not applicable.

•

If you are applying on behalf of a client, a document evidencing power of attorney must be included with the application.
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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

OMB Control No. 1018-0093
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•

Principal Officer is the person in charge of the listed business, corporation, public agency, Tribe, or institution. The principal
officer is the person responsible for the application and any permitted activities. Often the principal officer is a Director or President.

•

The Contact is the person at the business, corporation, public agency, or institution who will be available to answer questions
about the application or permitted activities. Often this is the preparer of the application. Each person that is associated with the
business that would need to access the business account needs to create their own contact in the ePermits system.

Application processing fee:
•

•

An application processing fee is required at the time of application, unless exempted under 50 CFR 13. The application processing
fee is assessed to partially cover the cost of processing a request. The fee does not guarantee the issuance of a permit, nor
will fees be refunded for applications for which processing has begun. Checks or money orders must be for the exact
amount for each application submitted. If you are making more than one request, you must submit a separate payment
for each request, otherwise your application will be returned.
Documentation of fee exempt status is not required for applications submitted by Federal, Tribal, State, or local
government agencies; but must be supplied by those applicants acting on behalf of such agencies. Such applications
must include a letter on agency letterhead and signed by the head of the unit of government for which the applicant is acting on
behalf, confirming that the applicant will be carrying out the permitted activity for the agency.

CERTIFICATION:
•

The individual identified in the Individual Applicant Section, the principal officer named in the Business Applicant Section, or person
with a valid power of attorney (documentation must be included in the application) must sign and date the application. This
signature legally binds the applicant to the statement of certification. You are certifying that you have read and understand the
regulations that apply to the permit. You are also certifying that all information 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 THE QUESTIONS ASSOCIATED WITH YOUR APPLICATION
Please continue to next page. DO NOT RETURN THIS PAGE WITH THE APPLICATION
Mail applications to: U.S. Fish and Wildlife Service; Division of Management Authority; Branch of Permits, MS:IA; 5275 Leesburg
Pike; Falls Church, Virginia 22041-3803 or as directed by specific applications.
If you would like expedited mailing, please enclose a self-addressed, pre-paid, computer-generated, courier service airway bill. If
unspecified, all documents will be mailed via the U.S. Postal Service.
Please refer to the fee schedule for the appropriate fees for the activity you are requesting.

If you are making more than one request, you must submit a separate payment
for each request, otherwise your application will be returned.

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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

INDIVIDUAL APPLICANTS
*First Name

Middle Name

*Last Name

*email address

Telephone number

*Street Address

*City

*State/Province

*Zip or Postal Code

*Country

If you wish to have your permit mailed to a different address, complete the following:
*Street Address

*State/Province

*City

*Zip or Postal Code

*Country

If you would like expedited mailing, please enclose a self-addressed, pre-paid, computer-generated, courier service
airway bill. If unspecified, all documents will be mailed via the U.S. Postal Service.

Have you or your client (if a broker applying on behalf of your client), been assessed a
civil penalty or convicted of any criminal provision of any statute or regulation relating
to the activity for which the application is filed; been convicted, or entered a plea of
guilty or nolo contendere, for a felony violation of the Lacey Act, the Migratory Bird
Treaty Act, or the Bald and Golden Eagle Protection Act; forfeited collateral; OR are
currently under charges for any violation of the laws mentioned above?
☐ No ☐ Yes
If you answered “Yes”, provide: a) the individual’s name; b) date of charge; c) charge(s);
d) location of incident; e) court and f) action taken for each violation. Please be aware
that a “Yes” response does not automatically disqualify you from getting a permit.

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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

Certification Statement
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 and date

Include a check or money order, payable to the U.S. FISH AND WILDLIFE SERVICE, as
a nonrefundable processing fee [50 CFR 13.11(d)(4)] (see instructions above).
Federal, Tribal, State, and local government agencies, and those acting on behalf of such
agencies, are exempt from the processing fee – attach documentation of fee exempt
status as outlined in instructions. (50 CFR 13.11(d))
*Required fields. Applications without this information are subject to delays or returns.

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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

BUSINESS APPLICANTS
*Business Name

doing business as (dba)

*Indicate your business type:
__ Business or other for profit
__ Farm

__ Small business

__ Government (Federal/State/Local/Tribal)

__ Not-for-profit institution

Name that will appear on the permit if you are applying on behalf of an individual/business

*Primary Contact Name

*Primary Contact email address

*Business email address

*Preferred contact method (e.g. phone, email)

*Principal Officer Name

*Principal Officer Title

*Principal Officer email

Tax ID Number

*Business Phone

Alternate phone

*Street Address

*State/Province

*City

*Zip or Postal Code

*Country

If you wish to have your permit mailed to a different address, complete the following:
*Street Address

*State/Province

*City

*Zip or Postal Code

*Country

If you would like expedited mailing, please enclose a self-addressed, pre-paid, computer-generated, courier service
airway bill. If unspecified, all documents will be mailed via the U.S. Postal Service.

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OMB Control No. 1018-0093
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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

Have you or your client (if a broker applying on behalf of your client), been assessed a
civil penalty or convicted of any criminal provision of any statute or regulation relating to
the activity for which the application is filed; been convicted, or entered a plea of guilty or
nolo contendere, for a felony violation of the Lacey Act, the Migratory Bird Treaty Act, or
the Bald and Golden Eagle Protection Act; forfeited collateral; OR are currently under
charges for any violation of the laws mentioned above?
☐ No ☐ Yes
If you answered “Yes”, provide: a) the individual’s name; b) date of charge; c) charge(s);
d) location of incident; e) court and f) action taken for each violation. Please be aware that
a “Yes” response does not automatically disqualify you from getting a permit.

Certification Statement
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 and date

Include a check or money order, payable to the U.S. FISH AND WILDLIFE SERVICE, as
a nonrefundable processing fee [50 CFR 13.11(d)(4)] (see instructions above).
Federal, Tribal, State, and local government agencies, and those acting on behalf of such
agencies, are exempt from the processing fee – attach documentation of fee exempt
status as outlined in instructions. (50 CFR 13.11(d))
*Required fields. Applications without this information are subject to delays or returns
.

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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires xx/xx/xxxx

Letter of Authorization for Marine Mammals Rescue/Rehabilitation Purposes (MMPA/ESA)
Allow at least 4 to 6 months for the application to be processed. Applications for marine mammal permits
must be published in the Federal Register for a 30-day public comment period.
Use this application to request authorization to rescue, verify, transport, hold, provide critical care, and/or release
live marine mammals under the jurisdiction of the FWS (sea otters, marine otter, polar bears, walrus, manatees, and
dugong) for purposes of rescue and rehabilitation of live animals. This application may be used for the renewal and/or
amendment of an existing permit for these activities.
NOTE: Renewal and amendment requests require responses to all questions pertaining to your requested activity.
This form should NOT be used for:
•
•
•
•
•
•

Public display of marine mammals (use Form 3-200-43a), including import for public display under the
MMPA/ESA.
Scientific research (use Form 3-200-43b), including import/export under the MMPA/ESA for research purposes.
Enhancement under the MMPA and/or ESA, including import/export under the MMPA/ESA for enhancement of
the propagation or survival of the species (use Form 3-200-43c).
Domestic transfer of specimens (parts/samples), domestic live marine mammal transfers and non-releasability
requests (use Form 3-200-87).
Commercial or educational photography (use Form 3-200-86).
Activities involving marine mammals under jurisdiction of the National Marine Fisheries Service (NMFS) (whales,
dolphins, porpoises, seals and sea lions); please contact NMFS.

If you already have MMPA/ESA authorization and need a CITES permit:
•
•

•
•

Export or re-export of captive-held live animals: (use Form 3-200-53)
Export or re-export of parts or biological samples:
o marine mammals listed on CITES Appendix II or III (use Form 3-200-29).
o marine mammals listed on CITES Appendix I (use Form 3-200-37e).
For CITES introduction from the sea (use Form 3-200-31).
Provide a copy of your FWS or NOAA Fisheries MMPA/ESA authorization with your CITES application.

All international shipment(s) must be through a CITES designated port. A list of designated ports (where a wildlife
inspector is posted) is available from the list of designated ports. If you wish to use a port not listed, please contact the
Office of Law Enforcement for a Designated Port Exemption Permit (form 3-200-2).
Please review the complete application carefully before beginning. Provide complete answers to all the
questions in the sections relevant to the activity for which you are requesting authorization. If a question is not
applicable, answer with “N/A”. If you provide additional information as attachments, indicate the application question
number you are addressing. If you are applying for multiple species and/or activities, be sure to indicate which
species/activity(ies) you are addressing in each response.

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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

OMB Control No. 1018-0093
Expires xx/xx/xxxx

Rescue and Rehabilitation of Marine Mammals
This application is for (choose all that apply):

☐ A new permit
☐ Renewal of permit # ____________________________
☐ Amendment of permit # __________________________
This application is for the following animals (Genus, species, common name)

Rescue and Rehabilitation and/or Release 1 of stranded Marine Mammals
Provide a copy of any other applicable Federal, local, or state permissions (e.g., National Wildlife Refuge Special Use
Permit, NOAA National Marine Sanctuary permit) required to conduct your proposed work. Indicate whether you have
applied for, secured, or will apply for such permissions (please provide contact information).
1. Provide a list of all non-target marine mammals and ESA listed species that occur within the area that your rescues
would take place.
2. What precautions would be taken to minimize the likelihood that harassment or take would occur on non-target
animals?
3. Please explain the actions that you would take if non-target animals were harassed and/or taken (e.g., killed or
injured).
The MMPA Letter of Authorization (LOA) or, for ESA-listed species, the combined MMPA LOA and ESA permit would
provide authorization for individuals or institutions to work as cooperators for the purpose(s) of rescue, rehabilitation,
and/or release of specified distressed marine mammals. Marine mammal rescues are dangerous activities that require
trained staff, specialized equipment, and clear communication among stranding partners. The FWS provides opportunities
for different levels of involvement for approved cooperators: verifiers, rescuers, transporters, critical care facilities, and
rehabilitation/holding facilities. These roles are defined within this application.
NOTE: A separate CITES permit will be required from the U.S. Division of Management Authority prior to the import of
CITES Appendix I species.
4. Are you or your organization currently conducting research activities with marine mammals?

☐ No

☐ Yes; provide the permit number under which you are conducting research ____________________
5. What type of authorization are you requesting (check all that apply)

☐ LOA under MMPA Sections 109(h)/112(c)
☐ ESA permit for enhancement of propagation or survival of the species
☐ Sub-permittee under ESA permit #___________________________

1

The term “stranding” as defined by the MMPA means an event in the wild in which: a) a marine mammal is dead and is on a beach or shore of the
United States or in the waters under the jurisdiction of the United States (including any navigable waters); OR b) a marine mammal is alive and is on a
beach or shore of the United States and unable to return to the water, on a beach or shore of the United States and, although able to return to the water,
is in need of apparent medical attention, or in the waters under the jurisdictions of the United State (including any navigable water), but is unable to
return to its natural habitat under its own power or without assistance.

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6. Are you also requesting to respond to:

☐ Oil spill events
☐ Other contaminant spill events; specify type(s):____________________________________________
☐ Other stranding events

Indicate at which level(s) of responsibility the cooperator will participate (check all that apply, and respond to the questions
below)
7.

8.

☐ Verifier: The role of verifiers is limited to answering requests to provide physical verification of the condition of
reported live, distressed animals and communicating the location and status of an animal to the appropriate person(s),
including the rescue program coordinator and, if so directed, the nearest approved rescue facility. In most cases
verifiers are required to stay with the animal until an approved rescue and transport team arrives. No physical
interaction with animals is authorized under this designation. Verifiers may handle animals only under the guidance of
an onsite designated rescue team(s).
a. Describe your organization’s experience in verifying the condition of reported live, distressed or injured animals of
each species requested (e.g., years of experience, number of responses)
b. Describe the qualifications of each of your staff who would be serving as a verifier in your organization that
demonstrates their ability to verify the conditions of reported, live, distressed animals of each species requested
(including any work and/or volunteer experience that describes where, with what authorized organization,
approximate number of hours, approximate number of verifications, and other relevant experience). Please use
the qualifications form at the end of this application to describe qualifications, for the marine mammal
species that is/are subject to this application.
c. List and describe any specialized training that your staff have completed to perform this duty, including where and
when the training occurred, which organization provided the training, types of training, and other relevant
information.
d. Describe numbers and types of
i.
vehicles (cars, trucks, boats, etc.) that will be used to travel to/from locations of reported, live, distressed
animals
ii.
communication devices that will be used to communicate with rescue responders (phones, radios, etc.);
and
iii.
any other related equipment.
e. Provide a statement that you will be available to respond to reports of live, distressed animals of the subject
species when needed.
☐ Rescuer: Rescuers respond to reports of injured and/or distressed animals and can initiate hand-on rescue and
transport efforts as needed. This level of involvement requires substantial expertise and training in species-specific
rescue techniques. Rescuers must meet U.S. Department of Agriculture (USDA) standards for Humane Handling, Care,
Treatment, and Transportation of Marine Mammals when rescuing live animals.
a. Describe your organization’s experience in rescuing distressed or injured animals of each species requested
(e.g., years of experience, number of responses).
b. Describe the qualifications of each of your staff who would be serving as a rescuer in your organization that
demonstrates their ability to rescue distressed animals of each species requested (including any work and/or
volunteer experience that describes where, with what authorized organization, approximate number of hours,
approximate number of rescues, and other relevant experience). List and describe any specialized training that
your staff have completed to perform this duty, including where and when the training occurred, which
organization provided the training, types of training, and other relevant information. Please use the
qualifications section at the end of this application to describe qualifications, for the marine mammal
species that is/are subject to this application.

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U.S. Department of the Interior

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c.

Describe how you meet or exceed USDA standards. Include a description of the number and types of
i.
vehicles (cars, trucks, boats, etc.) that will be used to travel to/from locations of reported, live, distressed
animals;
ii.
rescue equipment (nets, stretchers, etc.) that will be used for rescues;
iii.
communication devices that will be used to communicate with rescue responders (phones, radios, etc.);
iv.
any other related equipment.
d. Describe your methods of capture of the species of interest, including:
i.
methods of restraint and holding, including dimensions/type of holding container, if used;
ii.
minimum number of personnel participating in captures at any given time;
iii.
precautions you will take to avoid separating female-calf/pup/cub pairs, and protocol in the event they are
separated, including disposition of the separated calf/pup/cub;
iv.
precautions you will take to minimize incidental harassment of non-target animals of the target species;.
v.
provide a statement that you will be available to respond to reports of live, distressed animals of the subject
species when needed.
9.

☐ Transporter: Transporters respond to reports of injured and/or distressed animals and initiate transport efforts as
directed. This level of involvement requires substantial expertise and training in the species-specific transport
methodology, as well as the necessary equipment and trained staff to accompany and move the animals to or
between approved critical care and/or rehabilitation/holding facilities. Transporters must meet USDA standards for
Humane Handling, Care, Treatment, and Transportation of Marine Mammals when transporting live animals.
Transports must also be consistent with Animal Welfare Act requirements for transportation and FWS transport
regulations.
a. Describe your organization’s experience in transporting distressed or injured animals of each species requested
(e.g., years of experience, number of transports).
b. Describe the qualifications of each of your staff in your organization who would be accompanying animals during
transport, demonstrating their ability to transport, accompany, and support animals of the subject species
(including any work and/or volunteer experience that describes where, with what authorized organization,
approximate number of hours, approximate number of transports, and other relevant experience). List and
describe any specialized training that your staff have completed to perform each duty, including where and when
the training occurred, which organization provided the training, types of training, and other relevant information.
Please use the qualifications section at the end of this application to describe qualifications, for the
marine mammal species that is/are subject to this application.
c. Describe how you meet or exceed USDA standards:
i.
include a description of the number and types of vehicles (cars, trucks, boats, airplanes, etc.) that will be
used to transport animals of the subject species;
ii.
shipping containers that will be used to transport the animals (including type, construction, dimensions, and
weight);
iii.
other equipment that will be used in the transport of the animals (foam pads, water sprayers, stretchers,
etc.);
iv.
communication devices that will be used to communicate with rescue responders (phones, radios, etc.)
v.
any other related equipment;
vi.
describe how the subject animals will be cared for during transport, including the number of attending staff
and a description of the arrangements for watering or otherwise caring for the animals during transport.
d. Provide a statement that you will be available to respond to reports of live, distressed animals of the subject
species when needed.

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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

10.

11.

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☐ Critical Care Facility: These facilities hold and medically treat sick and/or injured animals whose lives would be
jeopardized if care was not provided. These facilities have the species-specific equipment, experience, and
credentials necessary to rescue, stabilize, rehabilitate, and release animals. These facilities may also provide longterm care, as needed, for generally healthy animals awaiting release, or they may provide long-term care for those
individuals designated as “non-releasable”. Critical care facilities must meet or exceed USDA standards for Humane
Handling, Care, Treatment, and Transportation of Marine Mammals when maintaining, treating, and holding live
animals.
a. Describe your organization’s experience in maintaining, holding, and caring for distressed or injured animals of
each species requested (e.g., years of experience, number of animals held.)
b. Describe the qualifications of each of your staff in your organization who would be caring for, handling, and
maintaining animals of the subject species, (including any work and/or volunteer experience that describes where,
with what authorized organization, approximate number of hours, approximate number of animals, and other
relevant experience). Please use the qualifications form at the end of this application to describe
qualifications, for the marine mammal species that is/are subject to this application.
c. For authorization as a critical care facility, you must have a qualified, critical care veterinarian. Provide the name
of the person assigned this role and describe his/her qualifications, including a qualification form that
demonstrates his/her ability to perform this role.
d. Describe how you meet or exceed USDA standards. Include a description of
i.
critical care and holding areas, including descriptions of holding tanks and haul-out areas. The description
should include photographs, drawings, and/or diagrams illustrating the area(s) and facility(ies) where
animals of the subject species will be held. When describing holding tanks, include dimensions (tank
length, width, depth, water volume); describe pumps and filtration systems in tanks (including type and
capacity and other relevant information); describe lifting apparatus; describe water heaters (including
degree to which tanks can be heated); describe water source and type (and ability to use freshwater,
saltwater and/or both); and any other relevant features;
ii.
the maximum number of animals of the subject species that can be housed at your facility;
iii.
the current distribution and number of animals of the subject species by holding tank at your facility (include
sex, age (if known), time in captivity, age/size class, calves/pups/cubs, etc.);
iv.
all deaths of the subject species at your facility within the past five years and the steps taken to prevent
them.
e. Describe quarantine plans, including location and timeframe.
f. Provide a copy of your USDA/APHIS Animal Welfare Act (AWA) license and your most recent APHIS inspection
report.
g. Provide a statement that you will be available to respond to reports of live, distressed animals of the subject
species when needed.
☐ Rehabilitation/Holding Facility: These facilities provide routine husbandry for generally healthy animals that

require a minimum of specialized treatments. These facilities may provide long-term care, as needed, for generally
healthy animals awaiting release, or they may provide long-term care for those individuals designated as nonreleasable. Holding facilities must meet USDA standards for Humane Handling, Care, Treatment, and Transportation
of Marine Mammals when holding live animals.
a. Describe your organization’s experience in maintaining and holding animals of each species requested (e.g.,
years of experience, number of animals held).
b. Describe the qualifications of each of your staff in your organization who would be caring for, handling, and
maintaining animals of the subject species, (including any work and/or volunteer experience that describes where,
with what authorized organization, approximate number of hours, approximate number of animals, and other
relevant experience). Please use the qualifications section at the end of this application to describe
qualifications, for the marine mammal species that is/are subject to this application.
c. For authorization as a holding facility, you must have a qualified, critical care veterinarian. Provide the name of
the person assigned this role and describe his/her qualifications, including a qualification form that demonstrates
his/her ability to perform this role.

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d. Describe how you meet or exceed USDA standards. Include a description of:
i.
holding areas, including descriptions of holding tanks and haul-out areas. The description should include
photographs, drawings, and/or diagrams illustrating the area(s) and facility(ies) where animals of the
subject species will be held. When describing holding tanks, include dimensions (tank length, width, depth,
water volume); describe pumps and filtration systems in tanks (including type and capacity and other
relevant information); describe lifting apparatus; describe water heaters (including degree to which tanks
can be heated); describe water source and type (and ability to use freshwater, saltwater and/or both); and
any other relevant features;
ii.
the maximum number of animals of the subject species that can be housed at your facility;
iii.
the current distribution and number of animals of the subject species by holding tank at your facility (include
sex, age (if known), time in captivity, age/size class, calves/pups/cubs, etc.);
iv.
all deaths of the subject species at your facility within the past five years and the steps taken to prevent
them.
e. Describe quarantine plans, including location and timeframe.
f. Provide a copy of your USDA/APHIS Animal Welfare Act (AWA) license and your most recent APHIS inspection
report.
g. Provide a statement that you will be available to respond to reports of live, distressed animals of the subject
species when needed
12. Are you seeking approval to display the animals while holding and maintaining them for rehabilitation purposes?
☐ No
☐ Yes, complete a-c below:
a. The facility is open to the general public without limitations or restrictions (other than by the charging of an
admission fee);
b. The facility offers a program for education or conservation purposes that is based on professionally recognized
standards of the public display community; and
c. Such display will not interfere with attainment of the objectives of the permitted/authorized activity.
13. Are you requesting photography authorizations for rescue/rehabilitation purposes?
☐ No
☐ Yes, complete a-b below explaining how photography will be used for the rehabilitation of the marine mammals:
a. Will closed circuit cameras be used?
b. Will Unmanned Aircraft System (UAS) devices be used? If so, provide:
i.
provide a short description on how the UAS device will be used for rescue rehab purposes.
ii.
dimensions, mass, and battery life of UAS;
iii.
will the UAS ever be beyond the line of sight?
iv.
does the device have an auto-return feature should the device fail?
v.
ground control station description (what it is, where it will be located, e.g., on shore or on vessel,
number of stations, and how close the station will be to animals);
vi.
spotter roles (e.g., one spotter monitoring the UAS, another for monitoring the ground control
station);
vii.
do you have the appropriate FAA permits/authorizations (including pilot licenses)?
viii.
provide the minimum flight altitude at sea level and/or ground level.
ix.
provide the minimum approach distances to animals.
x.
the names of the personnel who will pilot the aircraft and provide a qualification form for the UAS pilot.
xi.
mitigation measures you will use to minimize disturbance including specific measures you will use to avoid
separating female-calf/pup/cub pairs, and measures to ensure the UAS will not collide or crash into any of
the animals.

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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

14. Will animals be tagged prior to release?

☐ No
☐ Yes, provide responses to a-i below:

a.
b.
c.
d.
e.
f.
g.
h.
i.

The type of tag (including dimensions and mass).
The maximum number and total mass of tags to be attached to/implanted in an animal at a given time.
Methods and location of attachment.
If surgeries for implantable tags are being conducted, specify who will be conducting them, where (in the field or
in a facility), and if antibiotic prophylactics will be administered.
The maximum number of times an animal would be fitted with tags in a given year.
Would the instrument/tag have a release mechanism, or would the instrument/tag fall off?
Have the proposed MTIs been used previously on this species?
What are the potential adverse effects and the means of monitoring new tags for adverse effects?
What actions will be taken in the event that the MTI has a significant adverse impact on the animal(s), and what
is the method of animal release from the MTI?

. 15. Will post-release monitoring of released rescued animals be conducted? ☐ No ☐ Yes, explain process.

Qualifications
Instructions: Please fill out the below and enclose it in your application package. A separate form must be completed for
each person requesting to be listed as a principal investigator or co-investigator. Please only add one (1) qualification
form per individual.
Persons authorized as the Principal Investigator 2 (PI) and Co-Investigators 3 (CI) must demonstrate qualifications
commensurate with their duties. If sufficient experience is not provided, personnel may not be authorized to conduct the
proposed activities.
NOTE: All documentation submitted will be publicly available. DO NOT include personal information (e.g., social
security number, date of birth, home phone).
Check one:

☐ Principal Investigator

Relevant Education

Degree/Certifications

2
3

☐ Co-Investigator

Major/Field of Study

Institution and Location

The individual(s) primarily responsible for all authorized activities.
Individuals who are qualified to conduct authorized activities under the supervision of the on-site PI.

Year Received

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OMB Control No. 1018-0093
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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

Relevant Experience
Permit
Activity
requesting
to be a
PI/CI for

Job Title

Job work experience
related to the permit
activity

Affiliation

Location
(City, State,
Country)

Dates
(Year/Month/
Day)

Current Level of
Experience1

1Select

the level of experience:
Level 1: I have received education/training in performing this procedure but have not successfully performed the
procedure.
Level 2: I have performed this procedure while under supervision or training of an expert.
Level 3: I have performed this procedure without supervision.
Level 4: I am considered an expert in performing this procedure, and I have supervised or trained others in performing
this procedure.
NOTE: Phrases such as “assisted with,” or “participated in,” which qualify only as Level 1 experience and will not
adequately demonstrate your experience performing the procedure if you have Level 2 experience or above.

Relevant Training, Certificates, or Licenses
Include additional information to support your qualifications including specialized training (e.g., intrusive tagging, biopsy
sampling, Unmanned Aircraft Systems) and certificates or licenses (e.g., diver certification, Federal Aviation
Administration certification) received relevant to the activities identified in the table directly above. For training,
include description of training, year(s) received, and institution or expert who trained you. For certificates or licenses,
include year received and expiration date. For UAS pilots, include your total flight hours and FAA certification.

Relevant Peer-reviewed Publication History
List your relevant publication history to support your qualifications. This list need not be exhaustive but should
demonstrate that you have published and are reasonably likely to publish in peer-reviewed journals or make results of
permitted research available (2 page maximum).

Relevant Reports and Presentations
List other reports or presentations to support your qualifications as described above (1 page maximum).

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OMB Control No. 1018-0093
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FWS Form 3-200-43d (Rev. 02/2023)
U.S. Department of the Interior

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 Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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 which
affect protected species. This helps 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
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) in order provide the
U.S. Fish and Wildlife Service the information necessary, under the applicable laws governing the requested
activity, for which a permit is requested. 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
applicable 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. 1018-0093.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 9.75 hours (electronically) to 10 hours (paperbased), including 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.
Questions regarding permits from Management Authority should be sent to managementauthority@fws.gov.

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