Application to Introduce, Transfer, or Hold Imported Marine and Estuarine Organisms

Vessel Name

Vessel Use / Endorsement

Pleasure
Commercial

Official Number

Confirm Official Number

Application Date

Expiration Date

Participant ID

Email

Enter Email Confirm Email

New
Update

Aquaculture Operation Permit #

Aquaculture Operation Permit Year

Prior Introduce/Transfer Permit #

Prior Introduce/Transfer Permit Year

Introduce/Transfer Permit #

Introduce/Transfer Permit Year

Fish Dealer License #

Fish Dealer License Year

Issued to (select one):

Individual (complete the Individual Participant Information below)
Business Agent (complete the Business Participant Information and Individual Participant Information below)

Individual Participant Information

Name

First Middle Last Suffix

Date of Birth

Address

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

Phone

Business (Facility) Participant Information

Business Name

Business Agent Name (First, MI, Last)

Agent Date of Birth

Address

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

Phone

Specify Waterbody, applicable Lease / Franchise, if any, where the organisms will be placed:

List

Waterbody (where organism will be placed)	County	Zip Code	Shellfish Bottom Lease / Franchise #:	Water Column Lease #:	Other (specify):

In determining whether the proposed activity will pose a threat to native species or environments pursuant to 15A NCAC 3I.0104, the following information is requested:

Supplier:

Supplier Business Name

Address

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

Supplier Business Contact Name (First, MI, Last)

Years in Business for this Purpose

Telephone #

Waterbody, species, estimated size and number of organisms to be shipped. Different organism size or assessment group should be separate batches:

Waterbody of Origin

Species/Organism

Waterbody Classification

Approved
Conditionally Approved
Restricted
Conditionally Restricted
Prohibited

Estimated Size

Number of Organism

Planned Date of Shipment

Planned Date of Placement

Assessment Type:

Assessment Date

Assessment Result

Investigator

Investigator Qualifications

Lab/Facility Investigator Associated

Ploidy Status

Disease History for Subject Species in the Area; Or, if Closed System, Description of Closed System or Water Treatment:

Detailed Description of the Operation if Non-Native Species:

Facilities

Handling

Safeguards against Unwanted Associated Species

Justification for Use of a Particular Species

Any Other Information Deemed Necessary

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

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.

Credit Card

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Billing Address

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

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