Observer/catch provider permits and appeals

Observer/Catch Monitor Provider Permit Application Form Pacific Coast Groundfish Individual Fishing Quota

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, Northwest Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.nwr.noaa.gov

OMB Control No. 0648-0619; Expiration Date: 11/30/2014

INSTRUCTIONS

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to renew a provider permit. The provider permit authorizes an entity to provide observer and/or catch monitors to participants in the Pacific Coast Groundfish fishery trawl rationalization program. The permit is effective upon approval by NMFS.

Section A – Provider Information

The applicant must provide their legal name as registered in a U.S. state, tax identification number and indicate the state they are registered in. Also, the applicant must provide their business mailing address, business phone number and fax number and optionally, email address by crossing out the incorrect information and printing the updated information.

Section B – Current Endorsements

The applicant must indicate whether they are requesting an observer endorsement or catch monitor endorsement or both. If the applicant requests one endorsement and at a later time wishes to obtain the second endorsement, a separate application must be completed and submitted to NMFS.

Section C – Ownership/Employees/Management and Organization Structure

Please review the list of owners, employees and board of directors (if applicable). If the list is not current, please make changes as appropriate. If individuals have left the organization place a line through the name of the individual. If an individual has been added, please write in the person’s name and provide other information as required (i.e.; date of birth, title). If there are any significant changes [ ] in the management and organizational structure of the provider entity since your last application to NMFS, please prepare a statement that confirms there is no change. If there has been a change, please submit a revise your prior narrative and submit with this form

Section D – Applicant Experience and Qualifications

Describe any prior relevant experience or qualifications specific to each endorsement requested. You may use the space provided on the form below to describe experience/qualification or attach to the application a written narrative. If you attach a narrative make sure to organize the page such that narrative clearly addresses to each endorsement requested. Prior relevant experience includes but is not limited to: recruiting, hiring, deployment, personnel administration and placing/supporting individuals in remote field or marine work environments. Qualification elements may include the knowledge or educational background of owners and employees.

Section E – Description of Ability to Carryout Required Responsibilities/Duties

For the endorsement(s) you are applying for, please describe your ability to carry out the required responsibilities and duties listed for observers and/or catch monitors as described in regulation. You may use the space provided below to describe experience/qualification or attach to the application a written narrative. For an observer endorsement please refer to the following regulations to see the specific responsibilities and duties: observers on vessels in the shorebased fishery: 50 CFR 660.140(h); mothership fishery: 50 CFR 660.150(j) and catcher processor fishery: at 50 CFR 660.160(g). For catch monitor endorsement please refer to the regulations at 50 CFR 660.17(f). Please note that the requirements for observers for various fisheries and catch monitors may be unique and need to be specifically addressed in your application.

Section F – Conflict of Interest Certification

Please review the statement and indicate whether you affirm or do not affirm the statement by checking the appropriate box. One box must be checked for the application to be considered complete.

Section G – Criminal Convictions, Negative Performance Ratings on Federal Contract and Decertifcation Actions

Please review the statement and indicate whether you affirm or do not affirm the statement by checking the appropriate box. One box must be checked for the application to be considered complete.

Section H – Certification of Applicant and Notary

The provider or authorized representative must sign and date this form in the presence of a notary to certify that the individual signing the form have satisfactorily identified themselves. By signing and dating the form, the authorized representative acknowledges they are authorized to make the certification on behalf of the provider, and certifies that all information set forth in the form is true, correct and complete to the best of their knowledge and belief. The authorized representative must print their name. The form must be signed, dated and notarized to be considered complete.

Supplemental Documentation

Please provide any additional information or documents you feel may support your request for the provider permit and endorsement(s). The applicant must provide a check or money order for the application fee in the amount of payable to the US Department of Commerce/NOAA?