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DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

SENTRI Application

Approved OMB No. 1651-0121 Exp. 8-31-2014

1. Applicant's age is 14 years or younger (check box)

1a. (Check one box only)

First time applicant without vehicle

Applicant renewal

Card replacement

1b. SENTRI ID

First time applicant with vehicle

Add vehicle

Vehicle decal replacement

SECTION A - PERSONAL INFORMATION

2. Last/Paternal Name

2a. Maternal name

3. First name

4. Middle name (in full)

4a. Suffix

5. Other names used (e.g., maiden name, former name)

Nickname

6. Gender

7. Date of Birth (yyyy/mm/dd)

Male

Female

City

Country

State

Place of birth

9. Citizenship (Check all that apply.)

10. Residence

Canadian citizen

U.S. citizen

Mexican citizen

Other (Must Specify)

Canada

United States

Mexico

11. Proof of citizenship/residency/immigration status (Attach copies)

U.S. Alien Registration No.

Border Crossing Card No.

Birth Certificate No.

Passport No.

Country of Issuance

(Expiration Date)

(yyyy/mm/dd)

Other Type of Document

No.

(Expiration Date)

(yyyy/mm/dd)

Drivers license No.

(Attach Copy)

State and Country of Issuance

(Expiration Date)

(yyyy/mm/dd)

SECTION B - ADDRESS HISTORY FOR THE LAST 5 YEARS

12. Current address

(yyyy/mm)

13. Street Address

Apt. No.

14. City

15. Colonia/Neighborhood

As of what

date?

16. Country

17. State

18. Postal/Zip Code

19. Home telephone

20. Business telephone/Cell phone number

Ext.

Mailing address if different from residential address

21. Street Address

Apt. No.

22. City

23. Colonia/Neighborhood

24. Country

25. State

26. Postal/Zip Code

Previous residential addresses if current residence is less than five years (address history continued on page 4).

27.	(yyyy/mm)	(yyyy/mm)		28. Street Address		Apt. No.	29. City
	From:	To:

30. Colonia/Neighborhood			31. Country		32. State			33. Postal/Zip Code

34.	(yyyy/mm)	(yyyy/mm)		35. Street Address		Apt. No.	36. City
	From:	To:

37. Colonia/Neighborhood

38. Country

39. State

40. Postal/Zip Code

41.(yyyy/mm)

From:

(yyyy/mm) 42. Street Address

To:

Apt. No.

43. City

44. Colonia/Neighborhood

45. Country

46. State

47. Postal/Zip Code

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0121. The estimated average time to complete this application is 40 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.

CBP Form 823S (10/10)

SECTION C - EMPLOYMENT HISTORY FOR THE LAST 5 YEARS (if applicable)

48.

Current employer

(yyyy/mm)

49. Employer's name

From:

To:

50.

Street Address

Apt. No.

51. City

52. Colonia/Neighborhood

53. Country

54. State

55. Postal/Zip Code

56. Telephone number

Ext.

57. Occupation

Previous Employer name and address if current employer is less than five years (employment history continued on page 4).

58.

(yyyy/mm)

59. Employer's name

60. Street Address

Apt. No.

From:

To:

61. City

62. Colonia/Neighborhood

63. Country

64. State

65. Postal/Zip Code

SECTION D - ADDITIONAL INFORMATION

66.

Have you ever been convicted of an offense in any country?

What country were you convicted in?

Have you ever received a waiver of inadmissibility to the U.S. from CBP (former USINS)?

Have you ever been found in violation of customs or immigration laws?

If you have answered YES, please give details:

N o

Yes

SECTION E – UNITED STATES CONTACT INFORMATION

Note: If U.S. contact information is not completed, Customs and Border Protection (CBP) will attempt to contact applicant via telephone for U.S. contact information. Application will not be accepted, if no U.S. contact information is available.

67.Full Name

68.Street Address

69. U.S. City

U.S. State

Postal/Zip Code

SECTION F – VEHICLE DATA

Note: An applicant does not have to provide vehicle data to enroll in SENTRI (i.e. carpool). However, if an applicant wishes to utilize their vehicle in the SENTRI lane, he or she must provide the vehicle data. Vehicle can only be registered for those persons age 18 and over.

70.	Make

71.	Model

72.	Year

73.	Color

74.	VIN No.

75.	License Plate No.

76.	Country	77. State
76.	Country

Registered Owner Information

78.Last/Paternal Name

79.First name

78a. Maternal name

79a. Middle name (in full)	79b. Suffix

80.Gender Male

Female

81. Date of Birth (yyyy/mm/dd)

CBP Form 823S (10/10)

SECTION G - FEE PAYMENT (non-refundable)

82.				Please submit the amount below in US currency only.
				Please submit the amount below in US currency only.
All credit card fees will be processed as U.S. funds		VISA		MasterCard
All credit card fees will be processed as U.S. funds

	I am enclosing a certified check or money order payment			$
				$
		Discover		American Express
		Discover		American Express

Once an application has been processed, absolutely no refunds will be granted. No exceptions.

Card no.			Expiration Date (yyyy/mm)

Card holder's name (please print)

Card holder's signature

SECTION H - CERTIFICATION

83.

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, and biometric data may be shared among Customs and Immigration authorities in both Mexico 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 SENTRI program, including all instructions and notices accompanying this application.

Applicant

Name (please print)

Signature

Date (yyyy/mm/dd)

U.S. PRIVACY ACT STATEMENT

The authority to collect the information on this application, any supporting documentation, fingerprints, and other requested information is contained in Titles 8 and 19 of the U.S. Code and corresponding regulations. Furnishing the information on this form is voluntary; however, failure to provide all the requested information may result in the delay of a final decision or denial of your application. The information collected will be used to make a determination on your application. It may also be provided to other government agencies (Federal, state, local, and/or foreign) as permitted under the Privacy Act of 1974, 5 U.S.C. § 552a (2002), and other applicable law. All applicants are subject to a check of criminal information databases and other immigration and customs databases in order to determine eligibility for this program.

Please mail or take your completed application along with application fee to the nearest SENTRI Enrollment Center. Locations and addresses of SENTRI Enrollment Centers can be found at www.SENTRI.gov.

CBP Form 823S (10/10)

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

SENTRI Application - Continuation Sheet

Approved OMB No. 0651-0121 Exp. 10-31-2010

1b. SENTRI ID

SECTION A - PERSONAL INFORMATION

2. Last/Paternal Name

2a. Maternal name

3.	First name		4. Middle name (in full)					4a. Suffix

5.	Other names used (e.g., maiden name, former name)	Nickname		6. Gender			7. Date of Birth (yyyy/mm/dd)
					Male	Female
					Male	Female

SECTION B - ADDRESS HISTORY FOR THE LAST 5 YEARS - continued

Previous residential addresses if current residence is less than five years (address history continued from page 1).

1.(yyyy/mm)

From:

(yyyy/mm)

To:

2. Street Address

Apt. No.

3. City

4. Colonia/Neighborhood

5. Country

6. State

7. Postal/Zip Code

8.(yyyy/mm)

From:

(yyyy/mm) 9. Street Address

To:

Apt. No.

10. City

11. Colonia/Neighborhood

12. Country

13. State

14. Postal/Zip Code

15.(yyyy/mm)

From:

(yyyy/mm) 16. Street Address

To:

Apt. No.

17. City

18. Colonia/Neighborhood

19. Country

20. State

21. Postal/Zip Code

22.(yyyy/mm)

From:

(yyyy/mm)

To:

23. Street Address

Apt. No.

24. City

25. Colonia/Neighborhood

26. Country

27. State

28. Postal/Zip Code

SECTION C - EMPLOYMENT HISTORY FOR THE LAST 5 YEARS - continued

Previous Employer name and address if current employer is less than five years (employment history continued from page 2).

1.	(yyyy/mm)	(yyyy/mm)	2. Employer's name	3. Street Address
From:		To:

Apt. No.

4. City			5. Colonia/Neighborhood		6. Country	7. State		8. Postal/Zip Code

9.	(yyyy/mm)		(yyyy/mm)	10. Employer's name			11. Street Address		Apt. No.
From:		To:

12. City			13. Colonia/Neighborhood		14. Country	15. State		16. Postal/Zip Code

17.(yyyy/mm)

From:

(yyyy/mm) 18. Employer's name

To:

19. Street Address

Apt. No.

20. City

21. Colonia/Neighborhood

22. Country

23. State

24. Postal/Zip Code

25.	(yyyy/mm)		(yyyy/mm)	26. Employer's name			27. Street Address		Apt. No.
From:		To:

28. City			29. Colonia/Neighborhood		30. Country	31. State		32. Postal/Zip Code

33.	(yyyy/mm)		(yyyy/mm)	34. Employer's name			35. Street Address		Apt. No.
From:		To:

36. City			37. Colonia/Neighborhood		38. Country	39. State		40. Postal/Zip Code

CBP Form 823S (10/10)

Question	Answer
Form Name	Sentri Application Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	form sentri application, sentri application, application section sentri, customs protection sentri

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