Groundfish Observer Catch Monitor Provider Permit - Commercial Fishing Permits Center

Contact Information

Name

First Last

Email*

Enter Email Confirm Email

Phone*

Section A - Applicant Information

Vessel Name

Vessel Use / Endorsement*

Pleasure
Commercial

USCG Doc or State Registration Number*

Confirm USCG Doc or State Registration Number*

Legal Name of Applicant

First Middle Last

TIN (if business)

DOB (if person)

Stage Registered In (if business)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone

Business Fax

Business Email

Section B - Endorsement Request

Check one or both

Monetary
Non-Monetary

Section C - List of Owners, Board Members, Officers, Authorized Agents and Employees

List Names of All Current Owners, Board Members, Officers, Authorized Agents and Employees

Name	Date of Birth	Role in Applicant Organization

Section D - Description of Management and Organizational Structure

Please describe the management and structure of the applicant organization. At a minimum, such description should provide the general functional responsibilities of various staff, all office locations and their business addresses, business phone number, fax number and email addresses. Also, if a corporation attach articles of incorporation or if a partnership, attach the partnership agreement.

Section E - Applicant Prior Experience and Qualifications

For the endorsement(s) you are applying for, please describe any prior relevant experience or qualifications the applicant may have that would qualify them for this provider permit/endorsement(s). 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.

Observer Endorsement

Catch Monitor Endorsement

Section F - Description of Ability to Carry out Required Responsibilities/Duties

For the endorsement(s) you are applying for, please describe your ability to carry out the required provider 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.

Observer Endorsement

(see responsibilities/duties described for observers on vessels in the shorebased fishery: at 50 CFR 660.140(h); mothership fishery at 50 CFR 660.150(j) and catcher processor fishery at 50 CFR 660.160(g).)

Catch Monitor Endorsement

(responsibilities/duties given at 50 CFR 660.17(e))

Section G

Under penalty of perjury, I either Affirm or Do Not Affirm as specified below, that all owners, board members, officers, authorized agents, and employees, are free from the following:

Conflict of interest as described in 50 CFR § 660.18 (c)(3)

Affirm
Do Not Affirm

Criminal convictions

Affirm
Do Not Affirm

Any previous Federal contract with an unsatisfactory performance rating

Affirm
Do Not Affirm

Any previous decertification action while working as an observer, catch monitor, observer provider, or catch monitor provider

Affirm
Do Not Affirm

Application Fee

Price:

RENEWAL ADVANCED PAYMENT OPTION

No Additional Years
2 year renewal
3 year renewal
4 year renewal
5 year renewal

Total

$0.00

Applicant Signature

Consent*

I agree

I CERTIFY THAT THE RECITATIONS CONCERNING THE VESSEL: NAME, TONNAGE, DIMENSIONS, PROPULSION, OWNERSHIP, HAILING PORT, RESTRICTIONS, ENTITLEMENTS, REMARKS AND ENDORSEMENTS CONTAINED IN THE CERTIFICATE OF DOCUMENTATION REMAIN ABSOLUTELY THE SAME.

NAME:*

Type your full name to sign this secure webform

Signature*

CAPACITY OF PERSON SIGNING (E.G., OWNER, AGENT, TRUSTEE, GENERAL PARTNER, CORPORATE OFFICER, MEMBER)

Date

Authorization*

I agree

I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected permits. I understand that my application will be processed in the order in which it is received by Commercial Fishing Permits Center, a private fee-for-service documentation company, not owned or operated by any governmental agency. I understand that application and processing fees are non-refundable as per Commercial Fishing Permits Center's no refund policy. I understand that submitting another application for a license or permit will supersede the current/pending application for that license or permit. I understand that Commercial Fishing Permits Center does not issue or sell any licenses or permits.

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