3 186A Form – Fill Out and Use This PDF

1

SPECIES:

USFWS Band Number:__________________________

Sex:  Male

Female

Unknown

Source:

Captive-bred  Wild Microchip Number: ________________







Age:

Nestling

 Immature

Year of Hatch: _________

(if applicable)





Adult

2

SENDER (person transferring bird)

USFWS Permit No.: ______________________________________________

Name: _____________________________________________

Date of Transfer (or other action): ___________________

Address: ____________________________________________________________________________________________

City: _______________________________________________

State:

Zip:______________________

E-Mail Address: ______________________________________________________________________________________

Permit:



State Falconry



FWS Raptor Propagation



FWS Rehabilitation (see instructions)



Other:______________

Transfer:

Gift

Sale

Loan







If Release or Loss:



Release



Escape



Theft



Death -- Cause of Death:

3

RECIPIENT (person acquiring bird)

USFWS Permit No.: _______________________________________

Name: _________________________________________________________

Date of Acquisition: ___________________

Address: _____________________________________________________________________________________________

City:

State:

Zip: _______________________

E-Mail Address:_______________________________________________________________________________________

Permit Type:

State Falconry

 FWS Raptor Propagation

Other: _______________________________________





Type of Acquisition:

Gift

Purchase

Capture/Recapture (complete section 4)



Loan







4

CAPTURE OR RECAPTURE (bird taken from the wild; provide band number in Section 1)



Capture



Recapture

For all species, County (or comparable subdivision) and State of trapping location: ____________________________________

If you captured a gyrfalcon, what color is it?

Grey

Black

White

Unknown (Nestling)







5

RE-BANDING (to report the re-banding of a wild or captive-bred bird) REQUIRED: Old bands returned to Migratory Bird Permit Office

Old Number:

Microchip

 Seamless Metal



Yellow Plastic  Black Plastic



New Number:

Black Plastic

Microchip



Yellow Plastic





6CERTIFICATION. I certify that the information submitted above is true and correct to the best of my knowledge. I understand that making a false statement may subject me to the criminal penalties of 18 U.S.C. 1001.

Print name: ____________________________________________		Phone Number (with area code): ___________________
Signature of Permittee/Principal Officer:			Date of Signature:
(No stamped signatures. Electronic signatures accepted.)			(mm/dd/yyyy) ______________

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Form 3-186a (Rev. 04/2018)	OMB Control No. 1018-0022
U.S. Department of the Interior	Expires 04/30/2021

NOTICES

PRIVACY ACT STATEMENT

Authority: The information requested is authorized by the Migratory Bird Treaty Act (16 U.S.C. 703 et seq), and Parts 13 and 21 of Title 50 of the Code of Federal Regulations.

Purpose: To collect the contact information of individuals that hold Federal Raptor Propagation permits, Special Purpose Game Bird (SPGB) permits, Special Purpose Abatement (SPA) permits and State Falconry programs. The states use a FWS application to maintain information about the falconers and their birds.

Routine Uses: The information will be used to monitor disposition of captive birds and the take of birds from the wild. More information about the routine uses may be found in the Systems of Records Notice, FWS-21 Permits System.

Disclosure: Providing the requested information is voluntary. However, submission of the requested information is required to maintain Federal permit under the MBTA. Failure to disclose the requested information may be sufficient cause for revocation of the permit. If the information indicates a violation of a statute, regulation, rule, order or license, whether civil, criminal, or regulatory in nature, the information may be transferred to the appropriate Federal, State, local or foreign agency charged with investigating or prosecuting such violations.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary to used to monitor disposition of captive birds and the take of birds from the wild, for which a permit is requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. 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. 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. 1018-0022.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information to average 15 minutes, including time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803, or via email at

Info_Coll@fws.gov. Please do not send your completed form to this address.

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