Form 3-2273 Title 50 Certifying Official Form

F WS Form 3-2273 (Rev. 05/2023) OMB Control No. 1018-0078

U.S. Department of the Interior Expires ##/##/20##

TITLE 50 IMPORTATION REQUEST FORM

(For use by new applicants and those seeking recertification)

Please return your completed form to:

U.S. Fish and Wildlife Service

Branch of Hatchery Operations and Applied Science

5275 Leesburg Pike, MS: FAC

Attn: Title 50 Importation Request Form

Falls Church, VA 22041

USA

Name:      

Professional Degrees:      

     

Position Title:      

Current Place of Employment:      

Address:      

City:       State:       Zip Code:      

Work Phone:       Fax:       Email Address:      

Primary Duties:

     

     

     

Area of Expertise and Related Certifications:

     

     

     

Facilities Available for Diagnostic Tests:

     

     

Additional Equipment:

     

     

(If more space is required to adequately answer questions, please use an extra sheet.)

Signature: Date:      

NOTICES

Privacy Act Statement

Authority: The information requested is authorized by the Lacey Act (18 U.S.C. 42) and Title 50, Part 16 of the Code of Federal Regulations.

Purpose: The information collected is used to verify your professional qualifications as necessary to evaluate the health data for salmonid fish and their reproductive parts in the import request process.

Routine Uses: The collected information may be disclosed in accordance with the Privacy Act of 1974 and the routine uses listed System of Records Notice (SORN) INTERIOR/FWS-21, Permits System (September 4, 2003) 68 FR 52610; modification published (March 16, 2023) 88 FR 16277 and available at www.doi.gov/privacy/fws-notices.

Disclosure: Furnishing this information is voluntary; however, failure to provide all requested information may prevent FWS from receiving or renewing your Certifying Official credentials.

PAPERWORK REDUCTION ACT STATEMENT

The U.S. Fish and Wildlife Service collects this information subject to the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) in order to consider your request for certification as a Title 50 inspector under Title 50, Part 16, of the Code of Federal Regulations. Information requested in this form is required to obtain or retain a benefit. Failure to provide all requested information may be sufficient cause for the 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. 1018-0078.

ESTIMATED BURDEN STATEMENT

Public reporting for this collection of information is estimated to be 1 hour 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, MS: PRB (JAO/3W), 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.

FREEDOM OF INFORMATION ACT STATEMENT

Information provided to the Service is generally subject to release to the public under the Freedom of Information Act (FOIA). Certain information, however, may be subject to withholding if the Service determines that the information is a trade secret and/or commercial or financial information that is privileged or confidential. To the extent you are submitting business information that falls into one of these categories, you must clearly mark this information as "Business Confidential" in order for the Service to assess the applicability of FOIA Exemption 4. Any information provided by you that is not marked as “Business Confidential” will be considered releasable to the public under the FOIA [43 CFR 2.26 – 2.33].

Page 1 of 2