U.s. Fish And Wildlife Service Form 3-186a

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Department of the Interior
USFWS Use Only
Received in Regional
U.S. Fish and Wildlife Service
Office on
Form 3-186A
_____/______/_____
MIGRATORY BIRD ACQUISITION AND DISPOSITION REPORT
Initials:
Please see reverse for instructions
1
SPECIES:
USFWS Band Number:__________________________
Sex:
Male
Female
Unknown
Source:
Captive-bred
Wild Microchip Number: ________________
(if applicable)
Age:
Nestling
Immature
Adult
Year of Hatch: _________
2
SENDER (person transferring bird)
USFWS Permit No.: ______________________________________________
Name: _____________________________________________ Date of Transfer (or other action): ___________________
Address: ____________________________________________________________________________________________
City: _______________________________________________ State:
Zip:______________________
E-Mail Address: ______________________________________________________________________________________
Permit:
State Falconry
FWS Raptor Propagation
FWS Rehabilitation (see instructions)
Other:______________
If a Transfer:
Gift
Sale
Loan
If Release or Loss:
Release
Escape
Theft
Death -- Cause of Death:
3
RECIPIENT (person acquiring bird)
USFWS Permit No.: _______________________________________
Name: _________________________________________________________ Date of Acquisition: ___________________
Address: _____________________________________________________________________________________________
City:
State:
Zip: _______________________
E-Mail Address:_______________________________________________________________________________________
Permit Type:
State Falconry
FWS Raptor Propagation
Other: ________________________________________
Type of Acquisition:
Gift
Purchase
Loan
Capture/Recapture (complete section 4)
4
CAPTURE OR RECAPTURE
Capture
Recapture
(bird taken from the wild; provide band number in Section 1)
For all species, County (or comparable subdivision) and State of trapping location: ___________________________________
If you captured a gyrfalcon, what color is it?
Grey
Black
White
Unknown (Nestling)
5
RE-BANDING (to report the re-banding of a wild or captive-bred bird)
Old Number:
Seamless Metal
Yellow Plastic
Black Plastic
Microchip
New Number:
Yellow Plastic
Black Plastic
Microchip
CERTIFICATION. I certify that the information submitted above is true and correct to the best of my knowledge.
6
I understand that making a false statement may subject me to the criminal penalties of 18 U.S.C. 1001.
Print name:
Phone Number (with area code):
________________________________
__________
________________________
__
______________________
Signature
(in blue
ink) of permittee/principal officer. (No photocopied or stamped signatures)
Date of signature (mm/dd/yyyy)
Form 3-186A
Rev. 12/2013
OMB Control No. 1018-0022; Expires 5/31/17

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