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1. Personnel
1. Personnel
Name of Lead Applicant/Project Leader:
Organization:
Address:
City:	Prov/State:		Postal/ZIP Code:
Phone:	Cellular:		Fax:
Experience/Credentials: Please provide relevant supporting documentation.
Have you ever been issued an authorization to disturb a marine mammal? If yes, please provide copies.			Yes No
Will the activity be completed with assistants? If yes, please provide names below (attach list if necessary), describe qualifications that demonstrate the ability of the assistant to carry out the proposed activity and provide proof of qualifications (where relevant).			Yes No
Name of Assistant:		Name of Assistant:
Name of Assistant:		Name of Assistant:
Name of Assistant:		Name of Assistant:
Will assistants be working independently?			Yes No

3. Species information
3. Species information
Species targeted for disturbance that ARE listed on Schedule 1 of the Species at Risk Act: (Common name)



Species targeted for disturbance that are NOT Species at Risk: (Common name)


Identify non-targeted marine mammal species that may be found in the area where the proposed activity will take place and indicate which ones, if any, are listed on Schedule 1 of SARA.

4. Vessel, vehicle and/or aircraft information
4. Vessel, vehicle and/or aircraft information
Vessel name and CFV/Registration:
Vehicle make/model/licence number:
Aircraft make/model/licence number:
Drone make/model/serial number/weight/type of drone/registration number (for drones between 250g-25kg) or Special Flight Operations Certificate (SFOC) (for drones over 25kg):
Have you provided a recent electronic picture of the vessel/vehicle/aircraft (jpeg or bmp format)?	Yes No

5. Objective and methodology
5. Objective and methodology
Activity Objective:
Have you provided the activity plan/proposal?	Yes No

6. Category of disturbance
6. Category of disturbance
Describe the nature of disturbance:
Identify the criteria in subsection 38(1) of the Marine Mammal Regulations that apply to the proposed activity:
ADescribe in detail how the desired outcome of the proposed activity will be accomplished:
BIf the proposed activity is for the purpose of easing the pain and suffering of a marine mammal, will it result in the immediate death of a marine mammal?	Yes No If yes, describe the euthanasia method. (Provide a detailed document and required authorizations for any restricted tools or substances to be used in the proposed euthanasia) If no, describe the method for easing pain and suffering. (Provide a detailed document)
CIf the proposed activity falls within s. 38(1)(f), answer the following in a detailed document: Explain filming techniques, be specific. What type of audio-visual or other equipment will be used? Will you employ marine mammal observers? At what time of the day will filming occur? Will audio-visual or other equipment be left behind in the environment? Explain rationale. How close do you plan on getting to the marine mammal species?

7. Alternatives (for SARA-listed species only)
7. Alternatives (for SARA-listed species only)
Explain what alternatives to the proposed activity you have considered to reduce the impact on the species while achieving the desired results? How did you determine that the chosen method is the best solution?

8. Mitigation measures
8. Mitigation measures
What mitigation measures are planned, and how do they minimize the potential impacts on the target species and other species of marine mammal found in the area (individually and collectively)? What standards or best practices will be followed for mitigation purposes? Will you deviate from existing standards or best practices? If so, explain how and why.
Explain the diagnostic assessment or physical evaluation that will be carried out in respect of the marine mammal(s) before, during and after the disturbance.

9. Conservation and protection
9. Conservation and protection
Will the proposed activity contribute to the conservation and protection of marine mammals? Please explain.

I verify that the information provided for this application is true and valid.

Signature
Name of lead applicant/project leader:
Signature:	Date:
Name of DFO receiving officer:
Signature:	Date: