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pdfOMB Control #_1028-0082
Approval expires:
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SFR
Applic. No.
RF
Date
Sent
SP a b c d e f g h
ST
NE
SP
1a. ͕ New Permit
͕ Renewal Permit #___________
1. APPLICANT’S NAME – (Last, first, middle initial)
3. HEIGHT _____ft. _____in. WEIGHT ______lbs.
GENDER ____ Male _____ Female
HAIR COLOR_______
2. BIRTH DATE
(mm/dd/yyyy)
EYE COLOR______
4. HOME ADDRESS AND ZIP CODE – (͕ Use this address for
correspondence)
5. BUSINESS ADDRESS AND ZIP CODE -- (͕ Use this address for
correspondence)
Phone Number: Area Code (
Fax Number: Area Code (
HMail address:
Phone Number: Area Code: (
Fax Number: Area Code (
HMail address:
)_______-____________
)_______-____________
6. TYPE PERMIT APPLIED FOR:
) _______-____________
)_______-____________
6a. NAME AND ADDRESS OF SPONSORING ORGANIZATION OR MASTER
PERMITTEE
___ Master-Personal (do not complete item 6a)
___ Master-Station (Complete item 6a)
___ Subpermit (Complete item 6a)
7 DO YOU PRESENTLY POSSESS, HAVE YOU EVER POSSESSED, OR DO YOU HAVE APPLICATIONS PENDING FOR OTHER
FEDERAL MIGRATORY BIRD PERMITS? __ Yes __ No (if “yes” give type of permit, number, date of issue, expiration and/or application)
8. DO YOU WISH TO HAVE BLOOD SAMPLING AUTHORIZED? ___ NO ___ YES (if yes, please provide the BBL the following
information.)
Species _________________________________________
Master Permitee name, number and any Subpermitees that require
permissions
Site of blood draw or technique ______________________
Master Permittee
Subpermittees’ Names
Number
________________________________________________
Volume of blood to be taken? ________________________
Why is blood needed? How will it be used? ____________
Applicant’s qualifications (or attach a resume of experience)
9. DO YOU WISH TO HAVE FEATHER SAMPLING AUTHORIZED? ___ NO ___ YES
information.)
Master Permitee name, number and any Subpermitees that require
permissions
(if yes, please provide the BBL the following
Species _________________________________________
What feathers will be taken and how many? __________________
Master Permittee
_____________________________________________________
Number
Why are feathers needed? How will they be used?
Subpermittees’ Names
_________________________________________________________
Applicant’s qualifications (or attach a resume of experience)
10. SPECIES YOU PLAN TO MARK – by groups
___ a. Waterfowl – ducks, geese and swans
____ b. Migratory webless gamebirds – doves, pigeons, snipe,
coot, gallinules, woodcock, rails, sandhill cranes
___ c. Blackbirds – grackles, cowbirds, yellow-headed,
red- winged, tri-colored blackbirds, starlings.
____ d. All species except waterfowl, eagles, or
endangered/threatened species
____ e. “Endangered/threatened” species – those designated by the
Secretary of the Interior as endangered/ threatened.” Specify
which species:
_____________________________________________
____ f. Eagles – bald and/or golden
____ g. All raptors except eagles or “endangered/threatened”
____ h. Other. Specify: __________________________
11. INDICATE STATES OR COUNTRIES OTHER THAN YOUR STATE/COUNTRY OF RESIDENCE IN WHICH YOU WISH TO BAND
BIRDS – (Attach a brief statement of your need to band in any non-resident state.)
OMB Control #_1028-0082
Approval expires:7/31/2009
12. DO YOU WISH TO HAVE AUTHORIZATION TO USE:
MIST NETS
___ Yes ____ No
ROCKET NETS ___ Yes ____ No
CANNON NETS ___ Yes ____ No
(If “yes” to any of the above, please attach a resume with your experience with such nets, This information is needed to ensure that skills are present
before these devices are authorized.)
13. DO YOU WISH AUTHORIZATION AT THIS TIME TO USE AUXILIARY MARKERS IN ADDITION TO THE STANDARD
NUMBERED METAL LEG BAND? ___ No ___ Yes (if yes, please provide the BBL the following information)
Master Permit name, number and any Subpermitees that require
permissions
Species _________________________________________
Techniques used__________________________________
Master Permittee
Number
Type of marker used _______________________________
________________________________________________
Why are auxiliary markers needed? How will they be used?
Subpermittees’ Name
Applicant’s qualifications (or attach a resume of experience)
14. ATTACH A ONE PAGE DESCRIPTION OF WHAT YOU HOPE TO ACCOMPLISH BY BANDING BIRDS.
Permits are only issued for management banding and original research beneficial to the public and U.S. Geological Survey.
15. REFERENCES—(List namesHPDLODGGUHVVHV and complete PDLOLQJaddresses of at least three licensed bird banders or other ornithologists
whom we may consult concerning your qualifications for a federal bird marking permit.)
NOTICE
In accordance with the Paperwork Reduction Act (PUB.L. 96-511), Privacy Act of 1974 (PUB.L. 93-579), please be advised that:
1.
2.
3.
4.
5.
The gathering of information on migratory birds and their uses is authorized by the Migratory Bird Treaty Act (16 U.S.C. 703-711) and the Fish
and Wildlife Act of 1956 (16 U.S.C. 742d). The requested information is required as a condition of your migratory bird permit.
Information from this application will be used to further the understanding, management, and utilization of the North American migratory bird
resource, by Federal, State, and private conservation organizations, and the Canadian Wildlife Service.
Failure to answer any questions fully may be sufficient cause for the U.S. Geological Survey to deny your permit. Your participation in the
survey is voluntary.
In the event there is an indicated violation of a statute, regulation, rule, order, or license, whether civil, criminal, or regulatory in nature, the
requested information may be transferred to the appropriate Federal, State, local, or foreign agency charged with investigating or prosecuting
such violations.
In the event of litigation involving the records of the subject matter of the records, the requested information may be transferred to the U.S.
Department of Justice.
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FRPSOHWLQJRXUEDQGLQJUHFRUGV$OOQDPHVDQG LGHQWLI\LQJLQIRUPDWLRQDUHSURWHFWHGE\WKH3ULYDF\$FtRI | File Type | application/pdf |
| File Title | DO NOT FILL THIS BLOCK |
| Author | Terry Liddick |
| File Modified | 2016-01-25 |
| File Created | 2015-12-14 |