Transcription of NEXUS CARD FAMILY APPLICATION FORM
1 NEXUS card FAMILY APPLICATION FORMINSTRUCTIONS: 1. Please complete one NEXUS APPLICATION form per person. Complete the address and employment fields for the last five years in full, leaving NO gaps (including when unemployed or student) 2. Make sure you have entered your identity documents data correctly (including passport, birth certificate, driver's license numbers and expiration dates) 3. Send your entire completed package using one of the following methods: FAX APPLICATION package to (313) 731-1580 OR SAVE APPLICATION and email to DISCLAIMER By submitting an APPLICATION and paying our service fee, I agree to the following: 1. Please sign that you understand that Trusted Traveler Ltd and its website are not part of a government agency but a private company; that you have read our Terms and Conditions and Privacy Policy and agree with them; that you buy our services voluntarily.
2 2. NEXUS card will cost you $ service fee plus $50 government fee for background and security checks. You need to pay the first fee ($ ) through CCBill to start this process. 3. Trusted Traveler Ltd is not responsible for applicants who are denied by CBP and will not refund the fees paid. 4. I understand I am using Trusted Traveler Ltd to apply for my NEXUS program and I agree to the Terms and Conditions section of their website TRAVELER LTD e-mail: Fax: (313) 731-1580 FAX APPLICATION package to (313) 731-1580 OR SAVE it and e-mail it to Please sign here or print name that you understand and agree to our fees and conditions SERVICE FEE OPTIONS: YOU CAN PAY THE SERVICE FEE HERE FAMILY NEXUS APPLICATION for one adult and children: $ (USD) FAMILY NEXUS APPLICATION for two adults and children: $ (USD) FAMILY NEXUS APPLICATION for three adults and children: $ (USD) FAMILY NEXUS APPLICATION for three adults and children: $ (USD) CITIZENSHIP & NATIONALITY DRIVER'S LICENCE INFORMATION PERSONAL INFORMATION CONTACT DETAILS FIRST NAME:MIDDLE NAME: YYYY/MM/DDHEIGHTOTHER NAME.
3 EYE COLORBIRTH COUNTRY CITY OF BIRTH BIRTH STATE/PROV :HOME PHONE NUMBEREMAIL ADDRESSYOU ARE A:PASSPORT NUMBEREXPIRY YYYY/MM/DDEXPIRY YYYY/MM/DDCOUNTRY OF ISSUANCECOUNTRY OF ISSUANCECOUNTRY OF ISSUANCEPASSPORT NUMBERNAME ON PASSPORT/PR CARDEXACT NAME ON LICENCEDRIVER'S LICENCE NUMBERCOUNTRY OF ISSUANCESTATE/PROV OF ISSUANCEEXPIRY DATE YYYY/MM/DDUS CITIZEN CANADIAN CITIZENLAWFUL RESIDENT OF THE USALAWFUL RESIDENT OF CANADAMALEFEMALE GLOBAL ENTRY/SENTRI/ NEXUS PROGRAM ACCOUNT DETAILS GOES USER ID (If you have)EXPIRY DATE YYYY/MM/DD (OF YOUR NEXUS card )Membership/PASSID (9 DIGITS ON THE BACK OF YOUR TRUSTED TRAVELER card )CHECK HERE IF THIS IS AN ENHANCED DRIVERS LICENCE (EDL)BIRTH CERTIFICATE NUMBER ( not necessary ) CHECK IF THIS IS A COMMERICAL DRIVERS LICENCE (CDL)MOBILE PHONE NUMBERNAME ON BIRTH CERTIFICATE COUNTRY OF ISSUANCENOTE: WRITE CLEARLY AND LEGIBLY IN BLOCK CAPITALS OR TYPE YOUR DATA INTO THE form .
4 After completing the APPLICATION form , please save it in your device to keep the information you RESIDENT card OR CITIZENSHIP CERTIFICATE NUMBERNEXUS card FAMILY APPLICATION ADULT 1 Membership/PASSID (9 DIGITS ON THE BACK OF YOUR TRUSTED TRAVELER card )EXPIRY YYYY/MM/DD MAILING ADDRESS /if different to your current address/ CURRENT ADDRESS STREET NUMBERSTREET NAMECITYCOUNTRYSTATE/PROVINCEZIP/POSTAL CODEFROM YYYY/MM TO PRESENTSTREET NUMBERSTREET NAMECITYCOUNTRYSTATE/PROVINCEZIP/POSTAL CODEFROM YYYY/MMTO YYYY/MMFROM YYYY/MMTO YYYY/MMFROM YYYY/MMTO YYYY/MMSTREET NUMBERSTREET NAMECITYCOUNTRYSTREET NUMBERSTREET NAMECITYCOUNTRYSTREET NUMBERSTREET NAMECITYCOUNTRYFROM YYYY/MMTO YYYY/MMSTREET NUMBERSTREET NAMECITYCOUNTRYFROM YYYY/MMAPARTMENT TO PRESENTAPARTMENT ADDRESS HISTORY FOR THE LAST 5 YEARSSTATE/PROVINCEZIP/POSTAL CODESTATE/PROVINCEZIP/POSTAL CODESTATE/PROVINCEZIP/POSTAL CODESTATE/PROVINCEZIP/POSTAL CODE CURRENT EMPLOYMENT STATUS EMPLOYMENT STATUSFROM YYYY/MM TO PRESENTCURRENT EMPLOYERJOB TITLEEMPLOYER'S PHONESTREET NAMECITYCOUNTRYSTATE/PROVINCEZIP/POST CODEFROM YYYY/MMTO YYYY/MM EMPLOYERSTREET NUMBEREMPLOYER'S
5 PHONEEMPLOYMENT STATUSJOB TITLESTREET NAMESTREET NUMBERFROM YYYY/MMTO YYYY/MM EMPLOYEREMPLOYER'S PHONEEMPLOYMENT STATUSJOB TITLESTREET NUMBERFROM YYYY/MMTO YYYY/MM EMPLOYEREMPLOYER'S PHONEEMPLOYMENT STATUSJOB TITLESTREET NUMBERSTREET NAMESTREET NAMEEMPLOYMENT STATUSFROM YYYY/MMTO YYYY/MMJOB TITLE EMPLOYERSTREET NUMBERSTREET NAMEEMPLOYER'S PHONE EMPLOYMENT HISTORY FOR THE LAST 5 YEARSCITYCOUNTRYSTATE/PROVINCEZIP/POST CODECITYCOUNTRYSTATE/PROVINCEZIP/POST CODECITYCOUNTRYSTATE/PROVINCEZIP/POST CODECITYCOUNTRYSTATE/PROVINCEZIP/POST CODEIF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS PLEASE GIVE EXACT DETAILS BELOW: TRAVEL HISTORYHave you ever received a waiver of inadmissibility to the USA from a US government agency? NO YES Have you ever been approved by Citizenship and Immigration Canada for rehabilitation because of past criminal activity? NO YESHave you ever been found in violation of customs or immigration laws or other federal import laws?
6 NO YES FAX APPLICATION package to: (313) 731-1580 OR SAVE it and e-mail it to: YES NOHave you ever been convicted of an offense in any country for which you have not received a pardon? ADDITIONAL INFORMATIONT ravel HistoryTravel HistoryTravel HistoryPlease list all the countries you have traveled to in the last 5 years besides Canada, USA and sign here or print name that you understand and agree to our fees and conditions GOVERNMENT FEE PAYMENT Your card details are needed to pay the additional $50 for background and security checks. Your APPLICATION will not be processed without this. I agree to be charged $50 CBP fee for background and security checks I understand that the government fee is non-refundableExpiry DateCVV CodeCardholder Name Billing AddressCard NumberWhat is the CVV code? (The last 3 digits on the back of the card above the signature or 4 digits for American Express on the front above the card number) CITIZENSHIP & NATIONALITY DRIVER'S LICENCE INFORMATION PERSONAL INFORMATION CONTACT DETAILS FIRST NAME:MIDDLE NAME: YYYY/MM/DDHEIGHTOTHER NAME:EYE COLORBIRTH COUNTRY CITY OF BIRTH BIRTH STATE/PROV :HOME PHONE NUMBEREMAIL ADDRESSYOU ARE A.
7 PASSPORT NUMBEREXPIRY YYYY/MM/DDEXPIRY YYYY/MM/DDCOUNTRY OF ISSUANCECOUNTRY OF ISSUANCECOUNTRY OF ISSUANCEPASSPORT NUMBERNAME ON PASSPORT/PR CARDEXACT NAME ON LICENCEDRIVER'S LICENCE NUMBERCOUNTRY OF ISSUANCESTATE/PROV OF ISSUANCEEXPIRY DATE YYYY/MM/DDUS CITIZEN CANADIAN CITIZENLAWFUL RESIDENT OF THE USALAWFUL RESIDENT OF CANADAMALEFEMALE GLOBAL ENTRY/SENTRI/ NEXUS PROGRAM ACCOUNT DETAILS CHECK HERE IF THIS IS AN ENHANCED DRIVERS LICENCE (EDL)BIRTH CERTIFICATE NUMBER ( not necessary ) CHECK IF THIS IS A COMMERICAL DRIVERS LICENCE (CDL)MOBILE PHONE NUMBERNAME ON BIRTH CERTIFICATE NOTE: WRITE CLEARLY AND LEGIBLY IN BLOCK CAPITALS OR TYPE YOUR DATA INTO THE form . After completing the APPLICATION form , please save it in your device to keep the information you USER ID (If you have)EXPIRY DATE YYYY/MM/DD (OF YOUR NEXUS card )Membership/PASSID (9 DIGITS ON THE BACK OF YOUR TRUSTED TRAVELER card ) NEXUS card FAMILY APPLICATION ADULT 2 Membership/PASSID (9 DIGITS ON THE BACK OF YOUR TRUSTED TRAVELER card )
8 COUNTRY OF ISSUANCEPERMANENT RESIDENT card OR CITIZENSHIP CERTIFICATE NUMBEREXPIRY YYYY/MM/DD MAILING ADDRESS /if different to your current address/ CURRENT ADDRESS STREET NUMBERSTREET NAMECITYCOUNTRYSTATE/PROVINCEZIP/POSTAL CODEFROM YYYY/MM TO PRESENTSTREET NUMBERSTREET NAMECITYCOUNTRYSTATE/PROVINCEZIP/POSTAL CODEFROM YYYY/MMTO YYYY/MMFROM YYYY/MMTO YYYY/MMFROM YYYY/MMTO YYYY/MMSTREET NUMBERSTREET NAMECITYCOUNTRYSTREET NUMBERSTREET NAMECITYCOUNTRYSTREET NUMBERSTREET NAMECITYCOUNTRYFROM YYYY/MMTO YYYY/MMSTREET NUMBERSTREET NAMECITYCOUNTRYFROM YYYY/MMAPARTMENT TO PRESENTAPARTMENT ADDRESS HISTORY FOR THE LAST 5 YEARS CHECK IF THIS IS THE SAME AS ADULT 1. YOU MAY LEAVE THIS SECTION BLANK IF IT IS THE SAMECHECK IF THIS IS THE SAME AS ADULT 1. YOU MAY LEAVE THIS SECTION BLANK IF IT IS THE SAMECHECK IF THIS IS THE SAME AS ADULT 1. YOU MAY LEAVE THIS SECTION BLANK IF IT IS THE SAMESTATE/PROVINCEZIP/POSTAL CODESTATE/PROVINCEZIP/POSTAL CODESTATE/PROVINCEZIP/POSTAL CODESTATE/PROVINCEZIP/POSTAL CODE CURRENT EMPLOYMENT STATUS EMPLOYMENT STATUSFROM YYYY/MM TO PRESENTCURRENT EMPLOYERJOB TITLEEMPLOYER'S PHONESTREET NAMECITYCOUNTRYSTATE/PROVINCEZIP/POST CODEFROM YYYY/MMTO YYYY/MM EMPLOYERSTREET NUMBEREMPLOYER'S PHONEEMPLOYMENT STATUSJOB TITLESTREET NAMESTREET NUMBERFROM YYYY/MMTO YYYY/MM EMPLOYEREMPLOYER'S PHONEEMPLOYMENT STATUSJOB TITLESTREET NUMBERFROM YYYY/MMTO YYYY/MM EMPLOYEREMPLOYER'S PHONEEMPLOYMENT STATUSJOB TITLESTREET NUMBERSTREET NAMESTREET NAMEEMPLOYMENT STATUSFROM YYYY/MMTO YYYY/MMJOB TITLE EMPLOYERSTREET NUMBERSTREET NAMEEMPLOYER'S PHONE EMPLOYMENT HISTORY FOR THE LAST 5 YEARSCITYCOUNTRYSTATE/PROVINCEZIP/POST CODECITYCOUNTRYSTATE/PROVINCEZIP/POST CODECITYCOUNTRYSTATE/PROVINCEZIP/POST
9 CODECITYCOUNTRYSTATE/PROVINCEZIP/POST CODEIF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS PLEASE GIVE EXACT DETAILS BELOW: TRAVEL HISTORYHave you ever received a waiver of inadmissibility to the USA from a US government agency? NO YES Have you ever been approved by Citizenship and Immigration Canada for rehabilitation because of past criminal activity? NO YESHave you ever been found in violation of customs or immigration laws or other federal import laws? NO YES YES NOHave you ever been convicted of an offense in any country for which you have not received a pardon? ADDITIONAL INFORMATIONT ravel HistoryTravel HistoryTravel HistoryPlease list all the countries you have traveled to in the last 5 years besides Canada, USA and FEE PAYMENT Your card details are needed to pay the additional $50 for background and security checks. Your APPLICATION will not be processed without this.
10 I agree to be charged $50 CBP fee for background and security checks I understand that the government fee is non-refundableExpiry DateCVV CodeCardholder Name Billing AddressCard NumberWhat is the CVV code? (The last 3 digits on the back of the card above the signature or 4 digits for American Express on the front above the card number) FAX APPLICATION package to: (313) 731-1580 OR SAVE it and e-mail it to: sign here or print name that you understand and agree to our fees and conditions CITIZENSHIP & NATIONALITY DRIVER'S LICENCE INFORMATION PERSONAL INFORMATION CONTACT DETAILS FIRST NAME:MIDDLE NAME: YYYY/MM/DDHEIGHTOTHER NAME:EYE COLORBIRTH COUNTRY CITY OF BIRTH BIRTH STATE/PROV :HOME PHONE NUMBEREMAIL ADDRESSYOU ARE A:PASSPORT NUMBEREXPIRY YYYY/MM/DDEXPIRY YYYY/MM/DDCOUNTRY OF ISSUANCECOUNTRY OF ISSUANCECOUNTRY OF ISSUANCEPASSPORT NUMBERNAME ON PASSPORT/PR CARDEXACT NAME ON LICENCEDRIVER'S LICENCE NUMBERCOUNTRY OF ISSUANCESTATE/PROV OF ISSUANCEEXPIRY DATE YYYY/MM/DDUS CITIZEN CANADIAN CITIZENLAWFUL RESIDENT OF THE USALAWFUL RESIDENT OF CANADAMALEFEMALE GLOBAL ENTRY/SENTRI/ NEXUS PROGRAM ACCOUNT DETAILS CHECK HERE IF THIS IS AN ENHANCED DRIVERS LICENCE (EDL)BIRTH CERTIFICATE NUMBER ( not necessary ) CHECK IF THIS IS A COMMERICAL DRIVERS LICENCE (CDL)MOBILE PHONE NUMBERNAME ON BIRTH CERTIFICATE NOTE: WRITE CLEARLY AND LEGIBLY IN BLOCK CAPITALS OR TYPE YOUR DATA INTO THE form .
