Usfws Form 3-177 - Declaration For Importation Or Exportation Of Fish Or Wildlife
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1USFWS Form 3-177
U.S. FISH AND WILDLIFE SERVICE
USFWS Form 3-177
(Revised 03/10)
(Revised 12/03)
O.M.B. No. 1018-0012
DECLARATION FOR IMPORTATION
7. Name of Carrier:
O.M.B. No. 118-0012
Expiration Date: 04/30/2016
OR EXPORTATION OF
1. Date of Import/Export: (mm/dd/yyyy)
8. Air Waybill or Bill of Lading Number:
FISH OR WILDLIFE
___ ___ / ___ ___ / ___ ___ ___ ___
Master:
House:
2. Import/Export License Number:
9. Transportation Code: __________
3. Indicate One:
Import
Export
______________
______________
License #
State or Province
4. Port of Clearance:
_______ ________
10. Bonded Location for Inspection:
5. Purpose Code: ________
6. Customs Document Number (s)
11. Number of Cartons Containing Wildlife:
12. Markings on Cartons Containing
Wildlife:
13a.
(Complete name/U.S. address/telephone number/e-mail address)
14a.
(Complete name/foreign address/telephone number/e-mail address)
(Indicate One)
(Indicate One)
U.S. Importer
Foreign Importer
U.S. Exporter
Foreign Exporter
14b. Country Code
____ ____
Type Address Here
Type Address Here
14c. Identifier Number: ____________________ ID Type: ____________________
13b. Identifier Number: __________________ ID Type: __________________
15a. Customs Broker, Shipping Agent or Freight Forwarder:
(Complete business name/address/telephone and fax number/e-mail address)
15b. Identifier Number: __________________ ID Type: ________________
Type Address Here
15c. Contact Name: _______________________________________________
Species
16a. Scientific Name
17a. Foreign CITES Permit
18a. Description
19a.
20. Country
21.
Code
Number
Code
Quantity/Unit
of Species
Venomous
(Official Use
Origin Code
Live Wildlife
Only)
16b. Common Name
17b. U.S. CITES
18b. Source
19b. Total
Indicator
(ISO Code)
Code
Permit Number
Monetary Value
(Check if yes)
Knowingly making a false statement in a Declaration for Importation or Exportation of Fish or Wildlife
22. I certify under penalty of perjury that the information furnished
may subject the declarant to the penalty provided by 18 U.S.C. 1001 and 16 U.S.C. 3372(d)
is true and correct:
For Official Use Only
_______________________________ ____________
Action/Comments:
Signature
Date
______________________________________________________
Type or Print Name
Wildlife Declared:
Yes No
Wildlife Inspected:
None / Partial / Full
See Reverse Side of this Form for Privacy Act Notice
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