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Jul 2 3 2019 Form 3-200-20 OMS Control No. 1018~93 Ellplra& 08131/2020 JUL 2 3 2019 Department of Interior U.S. Fish and Wildlife Service Federal Fish and Wildlife Permit Application Form Type cl AciMly U.S. Fish aod Wildlle Service Division of Managemert Aulhority IMPORT OF SPORT-HUNTED TROPHIES under Appendix I of Branch of Permits, MS. IA 5276 Leesburg Pike the Convention on International Trade in Endangered Faus Church, VA 22041-3803 Species (CITES) and/or U.S. Endangered Species Act (ESA) 1-800-358-2104 or 703-358-2104 Complete Sections A or B, end C, D, end E of this eppllcetlon. U.S. edclross mey be required in Sedlon C, ,ee lnstructlon:s for details. lnttn.u::tlons on haw to make your appllc:atlon complete und help ■ voidunntteessary delaY9 .ire attached. Section A: Com in as an Individual t.l>.Fnl- 1.d.Sulb no. 3. .... P,,ndpol I. Pttmay C0'1lact n.,. c.a...-1a....- 7.L&-.-- SecUon C: AH a 1.a. CounrylP,ow,ce 11. Elkhart USA 2 c. Slate Z.d lip CDdell'ollll C:X:e 7.e. Caunfyfl',,,.,;,,... 21.Counlry Section D: All a llcants MUST com lete 1. Allach lhe nonrelundabl• appllc.illon proc"slng fH .r, \he lonn 0f • c:hec:I< or mDl'OY order payeble lo the U.S. FISH ANO WILDLIFE SERVICE In Ille amount of S100. Federal, Tri~ Slate, and local goverm,o<ll agendas, :ind lh0$0 acting on behd of auch aoe,,des. are exempl rrom the processing fee­ abch documenlalfcn of fH eXflr.1)1 !ilal11s 11S oull:ned In lnsll\ldlans 150 CFR 13 11(d)I 2. C.illlallon: I hllt9by c:er1Jly that I hiYD rvad and ■m famllar ¥.ill! lhe regulation, contelned"' 1111• SO P■rt 1, of,,.. Cod• ofFew,., ~ut•rlons and Iha other appl/Qble pan. In 1ubch•pter 8 of Cl>apter I cf Tide !O, and I centfy that tl\e lnlormatlan sutlmlbd In IIU applicat,on for a pormJl 11 c:cmpele and ao:uralelD 1M but o/ m leilcw! a ood bellal. I nd I.hat any false &IIIUlmentlteraln meyJ1Ubjoctm1 lo the criminal pen&lliH of 1a U.S.C. 1001. pied or stamped slgnawres) Date cf slgnalu111 (mm/dd/yyyy) se continue to next a a Rov. 11/2017 Pago 1 ol 7 Form 3•2ll0.20 0MB Cantrol No 101B-0093 Ei<plres 08/31/2020 E. IMPORT OF SPORT-HUNTED TROPHIES (Appendix I of CfTES and/or ESA) Note 1: This form should be used to request authori.tatlon to Import trophies of species llsted on Appendix I of CITES and/or as threatened or endangered under the ESA (examples include elephants, lions, cheetahs, wood bison, and markhor). PLEASE USE FORM 3-200-19 FOR SOUTHERN AFRICAN LEOPARD TROPHIES AND SOUTHERN WHITE RHINOCEROS TROPHIES TAKEN IN NAMIBIA. Note 2: If you hold an import permit for a trophy that you did not use, please return the unused original permit. If you are requesting reissuance of a permit because you have taken a trophy, but were unable to import it prior to the expiration of the permit. please use the renewal form {3-200-52) and return yoor original permit with that form. Note 3: Applrcalions for species listed as endangered under the U.S. Endangered Species Act are published In the Federal Register for a 30-day public comment period. Please allow at least 90 days for the application to be processed. Note 4: Sport-hunted trophy Is defined at 50 CFR 23.74 as follows: Sport-hunted trophy means a whole dead animal or a readily recognizable part or derivative of an animal specifically identified on the accompanying CITES document that meets the following criteria: Is raw, processed, or manufactured; Was legally obtained by the hunter through hunting for his or her personal use; Is being Imported, exported, or re-exported by or on behalf of the hunter as part of the transfer from its country of origin ultlmately to the hunter's country of usual residence;and Includes worked, manufactured, or handicraft Items made from the sport-hunted animal only when: I. Such items are contained in the same shipment as raw or tanned parts of the sport-hunted animal and are for lhe personal use of the hunter, ii. The quantity of such items Is no more than could reasonably be expected given the number of animals taken by the hunter as shown on the license or other documentation of the authorized hunt accompanying the shipment; and iii. The accompanying CITES doCtJmenls (export document and, If appropriate, import pennit) contain a complete itemization and description of all items included in the shipment. Note 5: Certain hunting trophies, including elephants, are subject to restrictions on their use after Import into the United States. Please see 50 CFR 23.55 for more information or contact the Division of Management Aulhority. Please 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 are submitting; please indicate the appllcatlon question number you are addressing. If applying for more than one trophy, be sure to answer quesUons 4-6 for each trophy addressed in this application. If importing Crophies from more than one country, you must submit a separate application for each shipment In order to obtain separate import permits. 1. Name and address where you wish the permit to be malled, it 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 the U.S. Postal Service. N/A 2. Who should we contact if we have questions about the application (name, phone number, and e-mail)? 11 • II ! l1f_.1 , , • • , Rsv 812017 Page2of7 Form 3-200-20 OMS Coniro: No. 1018-0093 Ex?ru 08/31/2020 3. Disqualification factor. A conVictlon, 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 disqua~fication 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 or 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 1he laws mentioned above? 0 No D Yes If you answered "Yes• to Question 3, provide: a) the individual's name; b) fjate 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 automatlcalty disqualify you from getting a permit. 4. For each trophy to be Imported, provide: a. Scientific name (genus, species, and, if appr.cabfe, subspecfes) and common name. Genus:Loxodonta Species: Loxodonta Afrlcana Common name:Elephant b. Sex (If known). Male 5. IF ANIMAL IS CURRENTLY LIVING IN THE WILD, please enter the following information: a. Country and place (area, re.gion, GlS coordinates, ranch , conservancy, management area, or hun•ting block, AND nearest city) where wildlife Is to be taken from the wild: N/A b. Date wildlife Is to be hunted: N/A c. Name of hunting outfitter, safari company, or professional hunter you will be hunting with: N/A 6. IF THE TROPHY HAS ALREADY BEEN TAKEN, please enter the following Information: a. Country and place (area, region, GlS coordinates, ranch, conservancy, management area, or hunting block, AND nearest city) where wUdnfe was removed from the wild: Country: Zimbabwe Management Area: Matetsi National Park Nearest City: Bulawayo Conservancy: Matetsi Unit 3 GIS: Grid Reference 5 18'30.448E I 025'47 .32S b. Date wildlife was hunted: April 21 , 2017 Rev 812017 Page 3 ar 7 Fenn 3-200-20 0MB Ccn\1'01 No 1018-0093 Expires 08/31/2020 c. Name of hunting outfitter, safari company, or professional hunter you hunted with: SAFARI OPERATOR Vexford lnveslments (Pvt) Ltd Plot 1 Tarqulnnla Farm Karoi PROFESSIONAL HUNTER Fidelis Muchenje d. The current location of the trophy (address and country) [the U.S. import permit will identify this country as the country of export/re-export and must match with the foreign export/re-export document]: Matabeleland Taxidermist 16 Birmingham Road Belmont Bulawayo Zimbabwe 7. Please provide a copy of any applicable foreign government permits or licenses that were required lo remove this animal from !he wild (if you have not hunted yet and do not currently hold any such permits or licenses, please indicate so). Documents included in package 8. Complete name and address of overseas person or business shipping the trophy to you. If you are applying to import a trophy directly from Namibia, you must provide the name and address of the professional hunter fisted on your Namibian hunting pennlt [this name wlll appear on the face of the export permit). Name: Business Name: Matabeleland Taxidermist Freight Consultants Address: 16 Binningham Road, Belmont 3 Trojan Street Qty.Bulawayo Belmont State/Province: N/A Bulawayo Country. Postal Code: Zimbabwe 9. For species listed under the U.S. Endangered Species Act, please be aware that the U.S. Fish and Wildlife Service (S8fVice) must make a finding that your activiUes will enhance or benefit wild populations of the species involved.
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