Nexus Application Form – Fill Out and Use This PDF

Government	Gouvernement	United States
of Canada	du Canada	of America

NEXUS APPLICATION

TIPS for completing the NEXUS Application Form

For ease in completion, pay special attention to the following tips. If information is missing or boxes are completed incorrectly, the application will be rejected and returned to you for corrections. To avoid this, please ensure that the application form is completed fully and accurately.

Do not send the original documents with this application send photocopies only. We will ask to see original documents at the enrolment centre during the interview.

Box 2: If the answer is no, proceed to box 5. If yes, complete boxes 3 and 4.

Box 5: Indicate English or French. We will correspond with you in the language of your choice, in accordance with Canadian law.

Section A - Personal Information

Box 8, Nickname: If you use a variation of your name (e.g., Fred or Freddie instead of Frederick) and if you have identification (e.g., passport, driver's licence, etc.) in that name, print that name in the box titled "Nickname."

Box 9, Other names used: If you have ever changed your name (including by marriage), provide the previous name(s) you have used and supporting documentation.

Citizenship/Admissibility/Permanent Resident status

Passport: Give required details of any current valid passport(s) you have.

Citizenship document refers to other documents not listed that confirm citizenship or admissibility, e.g., Citizenship Certificate or Card. (provide photocopy of documents and photo identification).

Visa/Permit: Complete if you have a student permit, work permit or other type of visa for admissibility to Canada or the U.S.

Box 15, 16: Canadian and United States citizens should not complete these boxes. Only those claiming permanent resident status need one of these documents to re-enter the country. Check ( ) the applicable box and provide information as required that proves your permanent resident status.

Boxes 14, 16, and 17: We need one clear photocopy of your documentation that shows both the front and the back, e.g., driver's licence, birth certificate, citizenship card, passport, permanent resident card. Each copy should be on a separate piece of paper and should include your home phone number. If you are photocopying a small document, please enlarge it on the photocopier, but make sure the copy is clear. Documents that do not contain a photo should be sent with a photo identification.

Please note that birth registration or baptismal certificates are not acceptable.

Section B - Address History for the Last Five Years

Boxes 18 through 25 and boxes 38 through 53: Please write the addresses of all your residences for the last five continuous years. Provide physical address, e.g., "911" address or legal land description. If there is not enough space on the application form, attach a separate sheet. There should be no gaps in time between addresses.

Section C - Employment History for the Last Five Years

Boxes 54 through 83: Please provide your employment history for the last five continuous years. There should be no gaps. Lack of employment will not disqualify you from being a member, if you are otherwise admissible to the U.S. and Canada and meet all other requirements. If there is not enough space on the application, attach a separate sheet. See the following explanation.

Box 54-55, Current Employer: Your current employer is the employer you are working for on the date you sign this form. Write the date you started working for your current employer e.g., from 2001/01, to the present, which is today's date.

Box 64, Specify Occupation: Describe or list the job you were paid for (e.g., driver). If you were not employed, or if you were attending school, college or university, please state which applies and give details in the space provided for employer information.

Box 65-66, Previous Employer, from: If you have worked for your current employer for less than five years, complete this section, and tell us the dates you worked for the employer you had before your current employer (e.g., from 2000/01 to 2003/07).

Section D - Fee Payment (Non-refundable)

Submit the correct fee.

Use a certified cheque, money order or fill out your credit card information.

If you are paying by credit card, include the name of the credit card, the 16-digit card number, and the card's expiry date. American Express, Visa, and MasterCard are acceptable. All Canadian and U.S. credit card fees for paper applications will be processed in Canadian funds.

Cardholder's signature: Signature required if paying by credit card.

Money orders stating "negotiable in U.S. only" will not be accepted. If you get the money order in the U.S., get an International money order.

Section E - Additional Information

Box 86: Answer all the questions in Section E. If you have answered "yes" to any of the questions, provide all the details on the application form or attach a separate sheet and include supporting documentation.

Section F - Non Custodial Adults

If applying for a child under 18 years of age, you must ensure that you provide documentary evidence that you have authority to apply on behalf of the child and that a photocopy of all legal documents regarding custody are submitted.

Section G - Certification

Clearly print your name. Remember to sign and date the certification statement on the final page of the application process. You should read the U.S. and Canadian privacy statements and the certification statement (box 87) on the application form carefully. (If the applicant is under the age of 18, the legal guardian or parent must sign this certification.)

Preferred Interview Location - You will be invited to an enrolment centre for an interview and finalization of the application. Please indicate where you would like to be interviewed.

Mail your signed application, photocopies of documents and fee payment as indicated:

U.S. and Ontario Residents NEXUS Program	Western Canada and Territories NEXUS Program	Atlantic and Quebec Residents
6080 Mcleod Road	6080 Mcleod Road	NEXUS Program
P.O. Box 126	P.O. Box 126	400 Place Youville
Niagara Falls ON L2E 6T1	Niagara Falls ON L2E 6T1	Montreal QC H2Y 2C2
CANADA	CANADA	CANADA

For additional information and recent updates regarding NEXUS please visit: www.nexus.gc.ca or call 1-866-NEXUS 26 (1-866-639-8726)

BSF658 E (13/08)

Continued on reverse

Please type or print. A separate payment and application form is required for each applicant.

SECTION A - PERSONAL INFORMATION

Citizenship/Admissibility/Permanent Resident status

13. Citizenship (Check all boxes that apply)

Canadian citizen

U.S. citizen

Other (Please specify which country and complete sections 14, 15 and 16)

14. Citizenship/Admissibility/Permanent Resident status document(s) (A photocopy of the document must be attached.)

Year

Month

Day

Passport

No.

Country of issuance

Date of birth

Name on passport

(Expiry date)

Passport

No.

Year

Month

Day

(2nd if

applicable)

Country of issuance

Date of birth

Name on passport

(Expiry date)

Citizenship

Year

Month

Day

No.

document

Country of issuance

Date of birth

Name on document

Type of document

Naturalization No.

Year

Month

Day

certificate

Country of issuance

Date of birth

Name on certificate

(Expiry date)

Birth

No.

Certificate

Country of issuance

Date of birth

Name on certificate

Prov./State of issuance

(not birth registration/attach photocopy of document and photo identification)

Year

Month

Day

Visa/permit

No.

Type of document

Country of issuance

Date of birth

Name on visa

(Expiry date)

Canadian and United States Citizens do not complete sections 15 and 16 and should proceed to section 17.

15. Permanent resident status document

Canada

United States

16. Permanent resident status document (A photocopy of the document must be attached. Applies only to those who are not Canadian or U.S. citizens.)

Record of

Landing in

No.

Canada

Country of issuance

Date of birth

Name

IMM 1000

Permanent

No.

Year

Month

Day

Resident

Card

Country of issuance

Date of birth

Name

(Expiry date)

Other Applicable Documents

17.

Do you have a valid driver's licence?

Yes

No

Please provide a photocopy of both sides of the document.

Year

Month

Day

Driver's licence

No.

Province/State of issue

Country of issuance

(Expiry date)

BSF658 E (13)

(Ce formulaire existe aussi en français.)

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SECTION B - ADDRESS HISTORY FOR THE LAST 5 YEARS (PROOF OF FULL 5 YEARS MAY BE REQUIRED AT INTERVIEW)

Current residential address (do not use P.O. box numbers or rural routes)

18.

Year

Month

19. Street number

20. Street name

21. Apt.

From:

To present:

22.

City

23. Province/State

24. Postal/Zip code

25.

Country

26.

Home phone number

27. Cell phone number

28. Business phone number

29.

E-mail address (if applicable)

(

)

(

)

(

)

Mailing address (if different from residential address)

30. Street number

31. Street name

32.

P.O. Box/RR #

33. Apt.

A – Previous residential address (attach a separate sheet if necessary)

38.	Year	Month			Year	Month	39. Street number	40. Street name			41. Apt.
From:			To:
42. City							43. Province/State		44. Postal/Zip code	45. Country

B – Previous residential address (attach a separate sheet if necessary)

46.

Year

Month

Year

Month

47. Street number

48. Street name

49. Apt.

From:

To:

50. City

51. Province/State

52. Postal/Zip code

53. Country

SECTION C - EMPLOYMENT HISTORY FOR THE LAST 5 YEARS (FULL 5 YEARS REQUIRED)

56. Street number	57. Street name	58. Apt.	59.	City
60. Province/State	61. Postal/Zip code 62. Country		63.	Employer's telephone number

( )

64.Please specify occupation (indicate student, self employed, unemployed, retired if applicable)

A – Previous employer name and address (attach a separate sheet if necessary).

65.

Year

Month

Year

Month

66.

Employer's name

From:

To:

67. Street number

68. Street name

69. Apt.

70.

City

71. Province/State

72. Postal/Zip code

73. Country

74.Please specify occupation (indicate student, self employed, unemployed, retired if applicable)

B – Previous employer name and address (attach a separate sheet if necessary).

75.

Year

Month

Year

Month

76.

Employer's name

From:

To:

77. Street number

78. Street name

79. Apt.

80.

City

81. Province/State

82. Postal/Zip code

83. Country

84.Please specify occupation (indicate student, self employed, unemployed, retired if applicable)

Continue on page 4

SECTION D - FEE PAYMENT (non-refundable) No fee is required for applicants under 18 years of age.

85.The combined Canada/U.S. processing fee is $50 Canadian or $50 U.S.

All credit card fees will be processed in Canadian funds only.

Payment in Canadian funds can be made by certified cheque or money order.

Payment in U.S. funds can be made by certified cheque drawn on a U.S. bank account or by an international money order. Note: Fees are for the service of processing the application and are non-refundable.

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SECTION E - ADDITIONAL INFORMATION

86.	Have you ever been convicted of an offence in any country for which you have not received a pardon?			Yes			No
	Have you ever received a waiver of inadmissibility to the U.S. from a U.S. government agency?
				Yes			No
	Have you ever been approved by Citizenship and Immigration Canada for rehabilitation because of past			Yes			No
	criminal activity?
	Have you ever been found in violation of customs or immigration laws or other federal import laws?			Yes			No
	If you have answered YES to any of the above, please give all details and provide copies of documentation.
	(Please use a separate sheet if additional space is required):

For background checks, you may be questioned by an officer about your full criminal history, including arrests and pardons.

Where did you hear about the program?

Website

Media

Trade show

Word of mouth

Border staff

Other

SECTION F - NON-CUSTODIAL ADULTS

Non-custodial adult parents or guardians must attach a copy of supporting documents such as a court order or letter of authorization if this application is for a child under the age of 18 who will be travelling with the non-custodial adult.

SECTION G - CERTIFICATION

	U.S. PRIVACY ACT STATEMENT		CANADA'S PRIVACY STATEMENT
The authority to collect the information on this application, any supporting			The information you provide on this form, including supporting documentation
documentation, fingerprints, and other requested information is contained in			and biometric data, is collected under the Customs Act and is protected
Titles 8 and 19 of the U.S. Code and corresponding regulations. Furnishing			under the Privacy Act. The information will be used to make a determination
the information on this form is voluntary; however, failure to provide all the			of your application and the operation of the programs, and may be shared
requested information may result in the delay of a final decision or denial of			with other government agencies in Canada and the United States of
your request. The information collected will be used to make a determination			America. The information will be retained in the Personal Information Bank #
on your application. It may also be provided to other government agencies			CBSA PPU 009. Instructions for obtaining information are provided in
(Federal, state, local, and/or foreign) as permitted under the Privacy Act of			Infosource, which is available at public libraries, government public reading
1974, 5 U.S.C. § 552a (2002) and other applicable law. All applicants are			rooms and on the Internet at: http://infosource.gc.ca. All applicants are
subject to a check of criminal information databases and other immigration			subject to a check of criminal information databases and other immigration
and customs databases in order to determine eligibility for this program.			and customs databases in order to determine eligibility for the program.
87.	I certify that all information given on this application, and in support of this application, was provided voluntarily and is true and complete. I understand that
	any information on this application, including any supporting documentation, background information, finger and iris biometric data will be shared among
	customs and immigration authorities in both Canada and the U.S. and among law enforcement and other government agencies in accordance with applicable
	laws. I certify that I have read, understood and agree to abide by all conditions required for use of the NEXUS program, including all instructions and notices
	accompanying this application.

	Applicant		Name (print)		Signature	Date
	or parent/legal guardian if		Name (print)		Signature	Date
	applicant is under the age of 18
	Preferred interview location
			Enrolment centre

For up-to-date listing, refer to Web site address www.nexus.gc.ca or call 1-866-NEXUS 26 (1-866-639-8726).

CHECKLIST before submitting application

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