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Declaration for Importation or Exportation of Fish or Wildlife

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Page ____ of _____ USFWS Form 3-177 USFWS Form (Revised 12/06) 3-177 (Revised 12/03) O.M.B. No. 1018-0012 O.M.B. No. 12/31/2009 Expiration Date: 1018-0012 1. Date of Import/Export: (mm/dd/yyyy) 2. Import/Export License Number: U.S. FISH AND WILDLIFE SERVICE DECLARATION FOR IMPORTATION OR EXPORTATION OF FISH OR WILDLIFE 7. Name of Carrier: 8. Air Waybill or Bill of Lading Number: Master: House: 9. Transportation Code: __________ 3. Indicate One: 4. Port of Clearance: Import ___ ___ Export ______________ License # ______________ State or Province 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. (Indicate One) (Complete name/U.S. address/telephone number/e-mail address) U.S. Importer U.S. Exporter Type Address Here 14a. (Indicate One) (Complete name/foreign address/telephone number/e-mail address) Foreign Importer Foreign Exporter 14b. Country Code ___ ___ Type Address Here 13b. Identifier Number: __________________ ID Type: __________________ 15a. Customs Broker, Shipping Agent or Freight Forwarder: (Complete business name/address/telephone and fax number/e-mail address) 14c. Identifier Number: ____________________ ID Type: ____________________ 15b. Identifier Number: __________________ ID Type: ________________ Type Address Here 15c. Contact Name: _______________________________________________ Species Code (Official Use Only) 16a. Scientific Name 17a. Foreign CITES Permit Number 17b. U.S. CITES Permit Number 18a. Description Code 18b. Source Code 19a. Quantity/Unit 19b. Total Monetary Value 20. Country of Species Origin Code (ISO Code) 16b. Common Name 21. Venomous Live Wildlife Indicator (Check if yes) Knowingly making a false statement in a Declaration for Importation or Exportation of Fish or Wildlife may subject the declarant to the penalty provided by 18 U.S.C. 1001 and 16 U.S.C. 3372(d) For Official Use Only 22. I certify under penalty of perjury that the information furnished is true and correct: _______________________________ ____________ Signature Date Action/Comments: ______________________________________________________ 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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