Form 3-200-40
OMB Control No. 1018-0093
Expires 08/31/2020
Department of Interior
U.S. Fish and Wildlife Service
Federal Fish and Wildlife Permit Application Form
U.S. Fish and Wildlife Service
Type of Activity
Division of Management Authority
EXPORT AND RE-IMPORT OF MUSEUM SPECIMENS under
Branch of Permits, MS: IA
the U.S. Endangered Species Act (ESA)
5275 Leesburg Pike
Falls Church, VA 22041-3803
1-800-358-2104 or 703-358-2104
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. Instructions on how to make your application complete and help avoid unnecessary delays are attached.
Section A: Complete if applying as an individual
1.a. Last Name
1.b. First Name
1.c. Middle Name/Initial
1.d. Suffix
2. Date of Birth (mm/dd/yyyy)
3. Telephone Number
3.a. Alternate Telephone Number
4. E-mail address
Section 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
4.c. Principal officer Middle name/initial
4.d. Suffix
5. Principal officer title
6. Primary contact name
7.a. Business telephone number
7.b. Alternate telephone number
7.c. Business fax number
7.d. Business e-mail address
Section C: 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
Section D: All applicants MUST complete
Attach the nonrefundable processing fee in the form of a check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount of $100.
1.
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)].
2.
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 of applicant/Principal Officer for permit (No photocopied or stamped signatures) Date of signature (mm/dd/yyyy)
Please continue to next page
Rev. 8/2017
Page 1 of 6
Form 3-200-40
OMB Control No. 1018-0093
Expires 08/31/2020
Department of Interior
U.S. Fish and Wildlife Service
Federal Fish and Wildlife Permit Application Form
U.S. Fish and Wildlife Service
Type of Activity
Division of Management Authority
EXPORT AND RE-IMPORT OF MUSEUM SPECIMENS under
Branch of Permits, MS: IA
the U.S. Endangered Species Act (ESA)
5275 Leesburg Pike
Falls Church, VA 22041-3803
1-800-358-2104 or 703-358-2104
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. Instructions on how to make your application complete and help avoid unnecessary delays are attached.
Section A: Complete if applying as an individual
1.a. Last Name
1.b. First Name
1.c. Middle Name/Initial
1.d. Suffix
2. Date of Birth (mm/dd/yyyy)
3. Telephone Number
3.a. Alternate Telephone Number
4. E-mail address
Section 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
4.c. Principal officer Middle name/initial
4.d. Suffix
5. Principal officer title
6. Primary contact name
7.a. Business telephone number
7.b. Alternate telephone number
7.c. Business fax number
7.d. Business e-mail address
Section C: 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
Section D: All applicants MUST complete
Attach the nonrefundable processing fee in the form of a check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount of $100.
1.
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)].
2.
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 of applicant/Principal Officer for permit (No photocopied or stamped signatures) Date of signature (mm/dd/yyyy)
Please continue to next page
Rev. 8/2017
Page 1 of 6
Form 3-200-40
OMB Control No. 1018-0093
Expires 08/31/2020
E.
EXPORT AND RE-IMPORT OF MUSEUM SPECIMENS (U.S. E
S
A
)
NDANGERED
PECIES
CT
Note 1: An ESA museum permit only authorizes export and re-import of specimens currently accessioned in your
museum. If specimens are protected by CITES, Marine Mammal Protection Act, Migratory Bird Treaty Act, or Bald and
Golden Eagle Protection Act, you would be required to obtain additional authorizations prior to any export or re-import of
specimens. Contact DMA for the required application.
Note 2: For the export or re-import of specimens that are not part of your museum collection or have not yet been
collected, please submit
Form
3-200-37.
For renewals, include the original permit and the annual report (see
Form
3-200-40a). The report is a summary of all
exports and re-imports conducted under your permit for the past year, including scientific name and common name of
specimen sent or received, date of activity, acquisition number, description, receiving/sending institution, and country.
1. Name and address where you wish the permit to be mailed, if different from page 1. If you would like
expedited shipping, please enclose a self-addressed, pre-paid, computer-generated, courier service airway
bill. If unspecified, all documents will be mailed via regular mail through the U.S. Postal Service.
2. Who should we contact if we have questions about the application (name, phone number, and e-mail)?
3. 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?
___ No
___ Yes
If you answered “Yes” to Question 3, 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.
4. This is for a:
New application
Renewal/amendment of permit # __________________
5. Is the institution or collection an accredited scientific institution/collection? If yes, indicate the name of the
accrediting organization. If additional relevant information about the institution is available on the web, please
provide the URL address. If no, provide additional information related to the institution’s standards for record-
keeping for and accessibility to the collection.
Yes; url address: ___________________________________
No
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Form 3-200-40
OMB Control No. 1018-0093
Expires 08/31/2020
6. Are the collections and associated data permanently housed and professionally curated? If yes, how long
have the collections been permanently housed and professionally curated. Provide the physical address for
the collection and the name and contact information for the curator.
Yes
No
7. Are all accessions properly recorded in a permanent catalogue?
Yes (If catalogue or collection is available online, please provide the url _______________________.
No
8. As appropriate, enter the approximate number of accessioned specimens:
Mammals
Birds
Other invertebrates
Insects/arachnids
Vascular plants
Reptiles/amphibians
Non-vascular plants
Fish
Other (provide description:________________________________)
9. Do you maintain any specimens protected under the Marine Mammal Protection Act?
Yes
No
a.
If "yes," do you intend to export or re-import these specimens? _______
b.
If “yes”, provide a copy of your MMPA authorization for this activity.
10. Do you maintain or intend to obtain any specimens protected under CITES?
Yes
No
a.
If "yes", do you intend to export or re-import these specimens? _______
b.
If “yes”, provide a copy of your CITES authorization for this activity.
11. Do you maintain or intend to obtain any specimens protected under the Migratory Bird Treaty Act?
Yes
No
a.
If "yes", do you intend to export or re-import these specimens? _______
b.
If “yes”, provide a copy of your MBTA authorization for this activity.
12. Do you maintain any specimens protected under the Bald and Golden Eagle Protection Act?
Yes
No
a.
If "yes", do you intend to export or re-import these specimens? _______
b.
If “yes”, provide a copy of your BGEPA authorization for this activity.
13. Are specimens accessible to qualified users from outside your institution?
Yes
No
ENTER approximate number
In the United States
Outside the United States
Loans last year
Exchanges last year
Donations last year
14. Are permanent records maintained on specimens that are loaned or transferred?
Yes
No
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Form 3-200-40
OMB Control No. 1018-0093
Expires 08/31/2020
15. Are specimens acquired primarily for the purpose of research, the results of which are to be reported in
scientific publications?
Yes
No
16. Are specimens prepared and the collections arranged in a manner that ensures their availability?
No
Yes
17. Are data on specimen labels, permanent catalogues, and other records as accurate as possible?
No
Yes
18. To the best of your knowledge, were the specimens in the collection acquired legally under the relevant laws of
the country where they were obtained and the United States (e.g., import permits, collection permits, take
permits, landowner permission)?
No
Yes
19. Are all specimens of endangered and threatened species permanently and centrally housed under direct
control of the scientific institution?
Yes
No
20. Are all specimens of endangered and threatened species intended for exchange managed in such a manner to
preclude their use solely as decorations or trophies, or for other purposes incompatible with the principles of
the ESA?
Yes
No
21. Please ATTACH (or enter below) a statement of how the activities carried out by your institution will enhance
or benefit the endangered or threatened species intended for exchange (e.g., identify recovery tasks from the
recovery plan, or describe how the research activities will benefit the species under the Act).
All international shipment(s) must be through a designated port. A
list of designated ports
(where an
inspector is posted) is available. 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).
Rev. 8/2017
Page 4 of 6
Form 3-200-40
OMB Control No. 1018-0093
Expires 08/31/2020
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.
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. 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 if importing/exporting under an Import/Export License.]:
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), a physical U.S. address is required.
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 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. 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 SECTION E
Please continue to next page. DO NOT RETURN THIS PAGE WITH THE APPLICATION
Page 5 of 6
Rev. 8/2017
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