BSF658 - NEXUS Application

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Government of Canada / United States of America

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
6080 Mcleod Road
P.O Box 126
Niagara Falls ON L2E 6T1
CANADA

Western Canada and Territories NEXUS Program
6080 Mcleod Road
P.O Box 126
Niagara Falls ONL2E 6T1
CANADA

Atlantic and Quebec Residents NEXUS Program
400 Place Youville
Montreal QC H2Y 2C2
CANADA

For additional information and recent updates regarding NEXUS please visit: www.nexus.gc.ca.

NEXUS Application

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

  • 1. Reason for application
    • First time applicant
    • Renewal after 5 years
    • Reapplication
  • 2. Are you a member of any other border crossing program? (No/Yes)
  • 3. Program name
  • 4. Membership number
  • 5. Preferred language (English/French)

Section A - Personal Information

  • 6. Surname (current)
  • 7. First name
  • 8. Middle name (in full)
    • Nickname
  • 9. Other names (e.g., name at birth, former name)
  • 10. Gender (Male/Female)
  • 11. Date of birth (Year/Month/Day)
  • 12. Place of birth (City, Prov./State, Country)

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.)
    • Passport
      • No.
      • Country of issuance
      • Date of birth
      • Name on passport
      • Expiry date (Year/Month/Day)
    • Passport (2nd if applicable)
      • No.
      • Country of issuance
      • Date of birth
      • Name on certificate
      • Expiry date (Year/Month/Day)
    • Citizenship document
      • No.
      • Country of issuance
      • Date of birth
      • Name on certificate
      • Year/Month/Day
      • Type of document
    • Naturalization certificate
      • No.
      • Country of issuance
      • Date of birth
      • Name on certificate
      • Expiry date (Year/Month/Day)
    • Birth Certificate (not birth registration/attach photocopy of document and photo identification)
      • No.
      • Country of issuance
      • Date of birth
      • Name on certificate
      • Prov./State of issuance
    • Visa/permit
      • No.
      • Country of issuance
      • Date of birth
      • Name on visa
      • Expiry date (Year/Month/Day)
      • Type of document

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

  • 15. Permanent resident status document
    • United States
    • Canada
  • 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 Canada IMM 1000
      • No.
      • Country of issuance
      • Date of birth
      • Name
    • Permanent Resident Card
      • No.
      • Country of issuance
      • Date of birth
      • Name
      • Expiry date (Year/Month/Day)

Other Applicable Documents

  • 17. Do you have a valid driver's licence?
    Please provide a photocopy of both sides of the document. (Yes/No)
    • Driver's licence
      • No.
      • Province/State of issue
      • Country of issuance
      • Expiry date (Year/Month/Day)

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. From: (Year/Month) To present:
  • 19. Street number
  • 20. Street name
  • 21. Apt.
  • 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.
  • 34. City
  • 35. Province/State
  • 36. Postal/Zip code
  • 37. Country

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

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

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

  • 46. From: (Year/Month) To: (Year/Month)
  • 47. Street number
  • 48. Street name
  • 49. Apt.
  • 50. City
  • 51. Province/State
  • 52. Postal/Zip code
  • 53. Country

Section C - Employment History for the Last 5 Years (full 5 years required)

  • 54. From: (Year/Month) To present:
  • 55. Current employer's name
  • 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. From: (Year/Month) To: (Year/Month)
  • 66. Employer's name
  • 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. From: (Year/Month) To: (Year/Month)
  • 76. Employer's name
  • 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)

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.
  • Visa/MasterCard/AMEX
    • Name appearing on card
    • Cardholder's signature
    • Card no.
    • Expiry date (MM/YY)
  • I am enclosing a certified cheque or international money order payable to the Receiver General for Canada.

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 criminal activity? (Yes/No)
  • 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

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 request. 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.

Canada's Privacy Statement

The information you provide in your application, including supporting documentation and biometric data, is collected by the Canada Border Services Agency ("CBSA") and is protected pursuant to both the Customs Act and the Privacy Act. In accordance with Canadian laws and regulations, this information will be shared with other government departments or agencies in Canada and the United States of America for the purpose of the operation of the NEXUS program and to conduct applicable checks and verifications to determine your eligibility and continued eligibility in the NEXUS program. If the required Information is not provided, your application may not be processed and the authorization may not be granted.

Individuals to whom the information relates have rights of access to, correction of and protection of, their personal information under the Privacy Act. The information collected is described in Personal Information Bank # CBSA PPU 031. Instructions for obtaining information are provided in Info Source, which is available at public libraries, government public reading rooms and on the Internet at:: http://infosource.gc.ca.

  • 87. Consent Statement
  • I understand that any information gathered for the purposes of this application, including any supporting documentation, background information, biometric data, and information obtained from the relevant files of law enforcement agencies, including intelligence gathered for law enforcement purposes, will be used for the purpose of the operation of the NEXUS program and to conduct applicable checks and verifications to determine eligibility and continued eligibility in the NEXUS program as described in the Presentation of Persons (2003) Regulations.
  • In addition, I understand that my personal information gathered for the purposes of this application, including my supporting documentation, background information, biometric data, and any other information obtained and collected for the purpose of the operation of the NEXUS program and to conduct applicable checks and verifications to determine my eligibility and continued eligibility in the NEXUS program, may be accessed and used by the CBSA, as well as by other government departments or agencies in Canada (including the Royal Canadian Mounted Police and the Canadian Security Intelligence Service), in accordance with the Privacy Act.
  • In addition to the above-noted use by the CBSA and other Canadian government departments and agencies, I also understand that the CBSA will share its determination of my eligibility to the NEXUS program, based on Canadian criteria, with the United States` Department of Homeland Security ("DHS"). The DHS will, in turn, disclose to the CBSA its determination of my eligibility based on the American criteria.
  • If you do not consent to the above noted collection, use and sharing of your personal information, your application cannot be processed and an authorization cannot be granted.
  • Do you consent to the above noted collection, use, and sharing of your personal information AND do you certify that all the information given on this application, and in support of this application, is provided voluntarily and is true, accurate, and complete and that you have read, understood, and agree to abide by all conditions applicable to the program to which you apply and to the use of the associated authorization, including all instructions and notices accompanying this application? (Yes/No)
  • Applicant
    • Name (print)
    • Signature
    • Date
  • or parent/legal guardian if applicant is under the age of 18
    • Name (print)
    • Signature
    • Date

Preferred interview location: (Enrolment centre)

For up-to-date listing, refer to Web site address www.nexus.gc.ca .

Checklist before submitting application

  • Completed all pages of application form.
  • Attach one (1) photocopy of your valid driver's licence (front and back).
  • Attach one (1) photocopy of each of the documents you have listed for citizenship, admissibility and, if applicable, permanent resident status.
  • Attach custodial documents, if applicable.
  • Provide all five (5) years of your address history (without gaps).
  • Sign Section D: card holders signature and expiry date if paying by credit card.
  • Provide all five (5) years of your employment history (without gaps).
  • Check the box, sign and date the consent statement in box 87.
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