OMB No. 1018-0093
Expires 05/31/2017
Department of the Interior
U.S. Fish and Wildlife Service
Federal Fish and Wildlife Permit Application Form
Return to:
U.S. Fish and Wildlife Service
(enter address from page 5 or 6 of application)
Type of Activity:
Commercial export of skins of 6 native species: bobcat, Lynx river
otter, Alaskan brown bear, Alaskan gray wolf, and American
alligator (CITES)
Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details.
See attached instruction pages for information on how to make your application complete and help avoid unnecessary delays.
A.
Complete if applying as an individual
1.a. Last name
1.b. First name
1.c. Middle name or initial
1.d. Suffix
2. Date of birth (mm/dd/yyyy)
3. Social Security No.
4. Occupation
5. Affiliation/ Doing business as (see instructions)
6.a. Telephone number
6.b. Alternate telephone number
6.c. Fax number
6.d. E-mail address
B.
Complete if applying on behalf of a business, corporation, public agency, Tribe, or institution
1.a. Name of business, agency, Tribe, or institution
1.b. Doing business as (dba)
2. Tax identification no.
3. Description of business, agency, Tribe, or institution
4.a. Principal officer Last name
4.b. Principal officer First name
5. Principal officer title
7.a. Business telephone number
4.c. Principal officer Middle name/ initial
4.d. Suffix
6. Primary contact name
7.b. Alternate telephone number
C.
7.c. Business fax number
7.d. Business e-mail address
All applicants complete address information
1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
1.b. City
1.c. State
1.d. Zip code/Postal code:
1.e. County/Province
1.f. Country
2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City
2.c. State
2.d. Zip code/Postal code:
2.e. County/Province
2.f. Country
D.
All applicants MUST complete
1.
Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount of $100, nonrefundable processing fee. 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))
Do you currently have or have you ever had any Federal Fish and Wildlife permits?
Yes If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: _________________________________No
2.
3.
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 (in blue ink) of applicant/person responsible for permit (No photocopied or stamped signatures)
Date of signature (mm/dd/yyyy)
Form 3-200-26
Please continue to next page E.
Rev. 02/2014
Page 1 of 8
Commercial export of skins of 6 native species: bobcat, river otter, Lynx, Alaskan brown bear, Alaskan
gray wolf, and American alligator (CITES)
Note: This application should be used solely for the export of furs and skins in the commercial trade.
Applications that are submitted to the Office of Law Enforcement (OLE) must be submitted to an OLE
office in the region where the applicant is located. If the skin is from a sport-hunted trophy, please use
Form 3-200-28 and submit the application to the Division of Management Authority (DMA).
Provide the following information. Complete all questions on the application. Mark questions that are not
applicable with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you submit,
indicate the application question number you are addressing.
1. Provide the following:
Scientific name
Common name
Alligator
mississippiensis
American
alligator
Ursus arctos
Alaskan brown
bear
Canis lupus
Alaskan gray
wolf
Lynx rufus
Bobcat
Lynx canadensis
Lynx
Lontra canadensis
Taken from
the Wild or
captivebred
Quantity
Description (e.g., raw
or tanned)
State(s)
where
specimens
were
harvested
River otter
2. Skins of these native species must be tagged with a CITES Tag at the time of export or re-export. Please see 50 §
23.69(c) and 23.70(d) for CITES tagging requirements. Provide a complete list of the CITES tag numbers (e.g.
FL MIS 0712345 - always refer to tag) or CITES replacement tag numbers (e.g. FWS REPL 0123456 – always
refer to tag). NOTE: Tags must be inserted through the skins and permanently locked in place at the time of
export. Replacement tags must be obtained before submitting your application (broken tags must be surrendered
at the time of requesting replacement tags).
Electronic submission of inventories: Because some applications contain extensive inventories, you may provide
electronic versions. Electronic submission may assist in expediting the processing of your application.. You may
include a disk containing the relevant information or check here ____ if you would like to be contacted to provide it
via email.
Form 3-200-26
Rev. 02/2014
Page 2 of 8
3. Applicants residing or located outside the United States conducting commercial activities. The name,
physical address and telephone number of your agent who is located in the United States and will maintain your
records for five (5) years from the expiration of the permit. If the location is the same as in item 3, then indicate
“same as 3." (This information is required under 50 CFR 13.12 and 13.46).
U.S. address (not a P.O. Box) for foreign applicant. (This information is required under 50 CFR 13.12).
Name:
Address:
Address:
City:
State/Province:
Country, Postal Code:
4. Provide the name and address of the recipient in the foreign country (if it is yourself, provide your
foreign address).
Name:
Address:
Address:
City:
State/Province:
Country, Postal Code:
5. Current location of skins (Address -City, State/Province, County, Postal Code):
Name:
Business Name:
Address:
Address:
City:
State/Province:
Country, Postal Code:
Form 3-200-26
Rev. 02/2014
Page 3 of 8
6.
Provide a copy of your valid Import/Export License.
7.
All international shipment(s) must be through a designated port. A list of designated ports (where an
inspector is posted) is available from http://www.fws.gov/le/designated-ports.html. 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).
8.
Name and address where you wish permit mailed, if different from page 1 (All permits will be mailed via
the U.S. Postal Service, unless you identify an alternative means below):
9.
If you wish the permit to be delivered by means other than USPS regular mail, provide an air bill, pre-paid
envelope, or billing information. If you do not have a pre-paid envelope or air bill and wish to pay for a
courier service with your credit card, please check the box below. Please DO NOT include credit card
number or other information; you will be contacted for this information.
□If a permit is issued, please send it via a courier service to the address on page 1 or question 8. I understand that
you will contact me for my credit card information once the application has been processed.
10. Who should we contact if we have questions about the application? (Include name, phone number, and
email):
11. Disqualification Factor. A conviction, or entry of 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 disqualifies any such
person from receiving or exercising the privileges of a permit, unless such disqualification has been expressly
waived by the Service Director in response to a written petition. (50 CFR 13.21(c)) Have you or any of the
owners of the business, if applying as a business, been convicted, or entered a plea of guilty or nolo contendere,
forfeited collateral, or are currently under charges for any violations of the laws mentioned above?
___ Yes ___ No 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.
Form 3-200-26
Rev. 02/2014
Page 4 of 8
CITES Permit Office
NOTE: The application must be submitted to Division of Management Authority or to the Office of Law Enforcement in the region
where the applicant is located.
Division of Management Authority (DMA)
Branch of Permits, MS: IA
5275 Leesburg Pike
Falls Church, VA 22041-3803
1-800-358-2104 or 703-358-2104
Office of Law Enforcement (OLE)
Region 1: Guam, Hawaii, Idaho, Oregon, & Washington
Guam
Honolulu
U.S. Fish & Wildlife Service
U.S. Fish & Wildlife Service
Office of Law Enforcement
Office of Law Enforcement
415 Chalan San Antonio Road, Suite 209
3375 Koapaka St., #B296
Tamuning, Guam 96913-3620
Honolulu, HI 96819-1867
Phone: (671) 647-6064
Phone: (808) 861-8525
Fax: (671) 647-6068
Fax: (808) 861-8515
Portland
U.S. Fish & Wildlife Service
Office of Law Enforcement
P.O. Box 55206
Portland, OR 97238
Phone: (503) 231-6135
Fax: (503) 231-6133
Blaine
U.S. Fish & Wildlife Service
Office of Law Enforcement
9925 Pacific Highway, Room 136
Blaine, WA 98230
Phone: (360) 332-5388
Fax: (360 )332-3010
Region 2: Arizona, New Mexico, Oklahoma, & Texas
U.S. Fish & Wildlife Service
Office of Law Enforcement
2545 W. Frye Road, Suite 8
Chandler, AZ 85224-6273
Phone: (480) 967-2007
Fax: (480) 966-9766
Region 3: Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Ohio, & Wisconsin
U.S. Fish & Wildlife Service
Office of Law Enforcement
10600 Higgins Road, Suite 200
Rosemont, IL 60018
Phone: (847) 298-3250 Ext. 110
Fax: (847) 298-7669
Region 4: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Puerto
Rico, & Tennessee
Atlanta
Miami
U.S. Fish & Wildlife Service
Mail:
U.S. Fish & Wildlife Service
Office of Law Enforcement
Office of Law Enforcement
4341 International Parkway, Suite #104
10426 NW 31 Terrace
Atlanta, GA 30354
Miami, FL 33172
Phone: (404) 763-7959
Fax: (404) 366-7031
Physical:
U.S. Fish & Wildlife Service
New Orleans
Mail:
Office of Law Enforcement
U.S. Fish & Wildlife Service
6105 NW 18th St., Room 405
Office of Law Enforcement
Miami, FL 33122
61387 Hwy 434
Phone: (305) 526-2994 or 2620
Lacombe, LA 70445
Fax: (305) 526-7480
Form 3-200-26
Rev. 02/2014
Page 5 of 8
Physical:
U.S. Fish & Wildlife Service
Office of Law Enforcement
2424 Edenborn, Room 100
Metairie, LA 70001
Phone: (504) 219-8870
Fax: (504) 219-8868
Region 5: Connecticut, District of Columbia, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New
York, Pennsylvania, Rhode Island, Vermont, Virginia, & West Virginia
U.S. Fish & Wildlife Service
Office of Law Enforcement
70 E. Sunrise Hwy, Suite 419
Valley Stream, NY 11580
Phone: (516) 825-3950
Fax: (516) 825-3597
Region 6: Colorado, Kansas, Montana, Nebraska, North Dakota, South Dakota, Utah, & Wyoming
U.S. Fish & Wildlife Service
Office of Law Enforcement
Denver International Airport
P.O. Box 492098
Denver, CO 80249
Phone: (303) 342-7430
Fax: (303) 342-7433
Region 7: Alaska
Anchorage
U.S. Fish & Wildlife Service
Office of Law Enforcement
P.O. Box 190045
4600 Postmark Drive, Suite NB207
Anchorage, AK 99519
Phone: (907) 271-6198
Fax: (907) 271-6199
Region 8: California and Nevada
Los Angeles
U.S. Fish & Wildlife Service
Office of Law Enforcement
370 Amapola Ave., #114
Torrance, CA 90501
Phone: (310) 328-6307
Fax: (310) 328-6399
Form 3-200-26
Fairbanks
U.S. Fish & Wildlife Service
Office of Law Enforcement
1412 Airport Way
Fairbanks, AK 99701
Phone: (907) 456-2335
Fax: (907) 456-2356
San Francisco
1633 Old Bayshore Highway, Suite 248
Burlingame, CA 94010
Phone: (650) 876-9078
Fax: (650) 876-9701
Rev. 02/2014
Page 6 of 8
APPLICATION FORM INSTRUCTIONS
The following instructions pertain to an 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.
GENERAL INSTRUCTIONS:
•
Complete all relevant questions in Sections A or B, C, D, and E.
•
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.
•
Print clearly or type in the information. Illegible applications may cause delays.
•
Sign the application in blue ink. Faxes or copies of the original signature will not be accepted.
•
Mail the original application to the address at the top of page one of the application 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).
•
Applications are processed in the order they are received.
SECTION A OR SECTION B:
Section A. Complete if applying as an individual [do not complete this section if applying for Import/Export License (3-200-3)]:
•
Enter the complete name of the responsible individual who will be the permittee if a permit is issued. Enter personal information that
identifies the applicant. Fax and e-mail, while helpful in processing, are not required.
•
If you are applying on behalf of a client, the personal information must pertain to the client, and a document evidencing power of attorney
must be included with the application.
•
Affiliation/ Doing business as (dba): business, agency, Tribe, organizational, or institutional affiliation directly related to the activity
requested in the application (e.g., a taxidermist is an individual whose business can directly relate to the requested activity). The Division
of Management Authority (DMA) and the Office of Law Enforcement (OLE) do not accept doing business as affiliations for individuals
(complete Section B)..
Section B. Complete if applying as a business, corporation, public agency, Tribe, or institution:
•
Enter the complete name of the business, agency, or institution that will be the permittee if a permit is issued. Give a brief description of
the type of business the applicant is engaged in. Provide contact phone number(s) of the business. If you are applying on behalf of a client,
a document evidencing power of attorney must be included with the application.
•
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. Primary 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.
ALL APPLICANTS COMPLETE SECTION C:
•
For all applications submitted to the Division of Management Authority (DMA) and Office of Law Enforcement (OLE), a physical U.S.
address is required. Province and Country blocks are provided for those USFWS programs that use foreign addresses and are not required
by DMA.
•
Mailing address is the address to which communications from USFWS should be mailed if different from applicant’s physical address.
ALL APPLICANTS COMPLETE SECTION D:
Section D.1 Application processing fee:
•
An application processing fee is required at the time of application, unless exempted under 50 CFR13. 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.
•
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.
Section D.2 Federal Fish and Wildlife permits:
•
List the number(s) of your most recent issued USFWS permit. If applying for re-issuance of a CITES permit, the original permit must be
returned with this application.
Section D.3 CERTIFICATION:
•
The individual identified in Section A, the principal officer named in Section B, or person with a valid power of attorney
(documentation must be included in the application) must sign and date the application in blue ink. 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.
Please continue to next page. DO NOT RETURN THIS PAGE WITH THE APPLICATION
Form 3-200-26
Rev. 02/2014
Page 7 of 8
APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT
Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised:
1.
The gathering of information on fish and wildlife is authorized by:
(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.html
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50 CFR 17;
Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;
Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;
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), http://www.cites.org/ , 50 CFR 23;
General Provisions, 50 CFR 10;
General Permit Procedures, 50 CFR 13; and
Wildlife Provisions (Import/export/transport), 50 CFR 14.
2.
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 above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the
request. We may not conduct or sponsor and you are not required to respond to collection of information unless it displays a currently valid OMB control
number.
3.
Certain applications for permits authorized under the Endangered Species Act of 1973 (16 U.S.C. 1539) and the Marine Mammal Protection Act of 1972
(16 U.S.C. 1374) will be published in the Federal Register as required by the two laws.
4.
Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the
disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Routine disclosure to subject matter experts, and Federal, Tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to
making a decision on an application for a permit or when necessary to accomplish a FWS function related to this system of records.
Routine disclosure to the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment
or notice of the decision on a permit application.
Routine disclosure to Federal, Tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied
to assure compliance with all applicable permitting requirements.
Routine disclosure to Captive-bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share
information on the captive breeding of these species.
Routine disclosure to Federal, Tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and
injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking
a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and
injured birds.
Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or
adjudicative or administrative body, under certain circumstances.
Routine disclosure to the appropriate Federal, Tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing,
or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we
need to monitor activities associated with a permit or regulated use.
Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.
Routine disclosure to provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor
to collect or compromise a Federal claim against the debtor or to consumer reporting agencies to prepare a commercial credit report for use by
the FWS.
5. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth
date, etc.) will be removed prior to any release of the application.
6. The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant burden
for an Import of Sport-hunted Trophies of Southern African Leopard, African Elephant, and Namibian Southern White Rhinoceros application is 20 minutes.
This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. You may direct
comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, Mail
Stop 2042-PDM, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.
Freedom of Information Act – Notice
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any
information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential
business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be accompanied by a
non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made available to the public under
FOIA [43 CFR 2.13(c)(4), 43 CFR 2.15(d)(1)(i)].
DO NOT RETURN THIS PAGE WITH THE APPLICATION
Form 3-200-26
Rev. 02/2014
Page 8 of 8
