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Please select the type of permit you are renewing:
Applicant, or for a station permit, Responsible Individual:
Station Name (if applicable):
Address to be used for correspondence:
In accordance with the Paperwork Reduction Act (PUB.L. 96-511), Privacy Act of 1974 (PUB.L. 93-579), please be advised that:
1. 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.
2. 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.
3. 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
4. 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.
5. 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
PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by The Migratory Bird Treaty Act, 16 U.S.C. 703-712. Your response is required to obtain or retain a benefit in the form of a permit. We estimate that it will take approximately 2 minutes to prepare and submit the form. 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 Office of Management and Budget control number. OMB has reviewed and approved this information collection and assigned OMB Control Number 1028-0082. You may submit comments on any aspect of this information collection, including the accuracy of the estimated burden hours and suggestions to reduce this burden. Send your comments to: Information Collection Clearance Officer, U.S. Geological Survey, 12201 Sunrise Valley Drive, MS 807, Reston, VA 20192.
I hereby certify that I have read and am familiar with the regulations contained in Title 50, Parts 13 & 21, of the Code of Federal Regulations and the other
applicable parts in Subchapter B of Chapter 1 of Title 50 (http://www.gpoaccess.gov/efr/), and I further certify that the information submitted in this
application for a permit is complete and accurate to the best of my knowledge and belief. I have not been convicted of, entered a plea of guilty or nolo
contender for a felony violation of the Lacey Act, Migratory Bird Treaty Act, or the Bald and Golden Eagle Protection Act. I understand that any false
statement herein may subject me to the criminal penalties of 18 U.S.C. 1001. I realize that I must comply with the rules and requirements in the Bird
Banding Manual and that marking and/or salvaging birds requires a significant amount of my time if a permit is issued. I agree to maintain and submit data
promptly and in the prescribed format, to cooperate fully with the U.S. Geological Survey in the Bird Marking Program, and to abide by the terms and
limitations of that permit.
NOTE: Please complete the Signed By and Date fields. By clicking on the SUBMIT button you will verify that you have read and agree to the information contained within this document.
Today's date is 05/25/2013
OMB Control #1028-0082
Approval expires: 1/31/2016
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U.S. Department of the
Interior | U.S. Geological Survey
Contact: WEB Admin