Polluted Area Relay Permit - Commercial Fishing Permits Center

Vessel Name

Vessel Use / Endorsement

Pleasure
Commercial

Official Number

Confirm Official Number

Name

First Middle Initial Last Suffix

Email

Enter Email Confirm Email

Address

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

Date of Birth

Phone

Business Participant Information:

Business Name

Business Agent Name: First, MI, Last

List

Lease/Franchise#	Location	County	Type Shellfish to be relayed (Oyster, Clams or Both)

Vessel Registration Number(s) or Commercial Fishing Vessel Registration or USCG Documentation Number(s)

(1)	(2)	(3)

Transplanter Information (All transplanters must have a valid shellfish license or SCFL/RSCFL with shellfish endorsement, and valid picture ID on file with the Division of Marine Fisheries):

Name (First, MI, Last)	Date of Birth	Telephone	Fisheries License #

CERTIFICATION STATEMENT (Must be completed and signed by the Permittee)

I, _____________ certify that:All the information provided and any supporting documentation provided is true, accurate, and complete. I, and all listed designees, currently have no marine fisheries licenses, permits, endorsements, or registrations under suspension or revocation, and the privilege to hold such licenses, permits, endorsements, or registrations is not revoked or suspended. I, and all listed designees, have not been convicted of four or more violations in any jurisdiction related to state or federal law or regulations involving or related to marine or estuarine resources. I have been provided a copy of permit rules and conditions that apply to this permit and I acknowledge failure to abide by all permit rules as well as conditions on this permit may result in termination of the permit. I understand that as a condition of accepting and use of this permit from the Division of Marine Fisheries, I agree to abide by all conditions of this permit and agree, that if specific conditions of this permit as identified on this permit are violated, or if false information was provided in the application for initial issuance, renewal or transfer, this permit may be suspended or revoked by the Fisheries Director. I understand that any false information or fraudulent disclosures may result in termination of this permit and related documents and possible criminal prosecution.

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

Card Details

Cardholder Name

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Billing Address

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

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