Form 823S SENTRI Application

DEPARTMENT OF HOMELAND SECURITY

Approved OMB No. 1651-0121
Exp. 10/31/2010

U.S. Customs and Border Protection
SENTRI Application
1. Applicant's age is 14 years or younger (check box)
1a. (Check one box only)

First time applicant without vehicle

First time applicant with vehicle

Add vehicle

Card replacement 1b. SENTRI ID

Applicant renewal
Vehicle decal replacement

SECTION A - PERSONAL INFORMATION
2. Last/Paternal Name

2a. Maternal name

4. Middle name (in full)

3. First name

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

Nickname

4a. Suffix

6. Gender

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

Male
City

8.

Female

Country

State

Place of birth
9. Citizenship (Check all that apply.)
Canadian citizen

10. Residence

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.

or

Border Crossing Card No.

Birth Certificate No.

Passport No.
(Expiration Date)
(yyyy/mm/dd)

Country of Issuance
No.

Other Type of Document

(Expiration Date)
(yyyy/mm/dd)
Drivers license No.
State and Country of Issuance

(Attach Copy)

(Expiration Date)
(yyyy/mm/dd)

SECTION B - ADDRESS HISTORY FOR THE LAST 5 YEARS
12. Current address
As of what
date?
16. Country

(yyyy/mm) 13. Street Address

Apt. No.

18. Postal/Zip Code

17. State

14. City

19. Home telephone

15. Colonia/Neighborhood

20. Business telephone/Cell phone number
Ext.

Mailing address if different from residential address
21. Street Address

23. Colonia/Neighborhood

24. Country

Apt. No.

25. State

22. City

26. Postal/Zip Code

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

27.
From:

31. Country

(yyyy/mm)
From:

32. State

(yyyy/mm) 35. Street Address

33. Postal/Zip Code

Apt. No.

36. City

To:

37. Colonia/Neighborhood

38. Country

(yyyy/mm)

41.

29. City

To:

30. Colonia/Neighborhood

34.

Apt. No.

(yyyy/mm) 28. Street Address

From:
44. Colonia/Neighborhood

39. State

(yyyy/mm) 42. Street Address

40. Postal/Zip Code

Apt. No.

43. City

To:
45. Country

46. State

47. Postal/Zip Code

According to the Paperwork Reduction Act, no persons are required to respond to a collection of Information unless it displays a valid OMB control number.
The valid OMB control number for this Information Collection is 1651-0121. The time required to complete this information collection is estimated to average
40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection.

CBP Form 823S (07/05)

SECTION C - EMPLOYMENT HISTORY FOR THE LAST 5 YEARS (if applicable)
48. Current employer

(yyyy/mm)

From:

(yyyy/mm) 49. Employer's name
To:

50. Street Address

Apt. No.

53. Country

51. City

52. Colonia/Neighborhood

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).
(yyyy/mm)

58.
From:

(yyyy/mm) 59. Employer's name

60. Street Address

Apt. No.

To:
62. Colonia/Neighborhood

61. City

63. Country

64. State

65. Postal/Zip Code

SECTION D - ADDITIONAL INFORMATION
66.
Have you ever been convicted of an offense in any country?

No

Yes

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

No

Yes

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

No

Yes

What country were you convicted in?

If you have answered YES, please give details:

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.
77. State

76. Country
Registered Owner Information

78a. Maternal name

78. Last/Paternal Name

79. First name

79a. Middle name (in full)

80. Gender
Male

79b. Suffix

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

CBP Form 823S (07/05)

SECTION G - FEE PAYMENT (non-refundable)
82.

Please submit the amount below in US currency only.
All credit card fees will be processed as U.S. funds
I am enclosing a certified check or money order payment

VISA

MasterCard

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.
Name (please print)

Applicant

Date (yyyy/mm/dd)

Signature

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.

CBP Form 823S (07/05)

DEPARTMENT OF HOMELAND SECURITY

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

U.S. Customs and Border Protection
SENTRI Application - Continuation Sheet
1b. SENTRI ID

SECTION A - PERSONAL INFORMATION
2a. Maternal name

2. Last/Paternal Name

4. Middle name (in full)

3. First name

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

4a. Suffix

Nickname

6. Gender
Male

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

1.
From:

(yyyy/mm) 2. Street Address

5. Country

4. Colonia/Neighborhood

8.
From:

3. City

7. Postal/Zip Code

Apt. No.

10. City

To:
12. Country

11. Colonia/Neighborhood

(yyyy/mm)
From:

13. State

14. Postal/Zip Code

Apt. No.

(yyyy/mm) 16. Street Address

17. City

To:
19. Country

18. Colonia/Neighborhood

(yyyy/mm)

22.

6. State

(yyyy/mm) 9. Street Address

(yyyy/mm)

15.

Apt. No.

To:

From:

20. State

21. Postal/Zip Code

(yyyy/mm) 23. Street Address

Apt. No.

24. City

To:
26. Country

25. Colonia/Neighborhood

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.

5. Colonia/Neighborhood

(yyyy/mm)

From:

(yyyy/mm)

(yyyy/mm)

Apt. No.

15. State

19. Street Address

16. Postal/Zip Code

Apt. No.

22. Country

(yyyy/mm) 26. Employer's name

23. State

27. Street Address

24. Postal/Zip Code

Apt. No.

To:
29. Colonia/Neighborhood

28. City

36. City

14. Country

(yyyy/mm) 18. Employer's name

21. Colonia/Neighborhood

From:

From:

8. Postal/Zip Code

To:

20. City

33.

7. State

11. Street Address

(yyyy/mm) 10. Employer's name

13. Colonia/Neighborhood

From:

25.

6. Country

To:

12. City

17.

Apt. No.

To:

4. City

9.

3. Street Address

(yyyy/mm) 2. Employer's name

(yyyy/mm)

From:

30. Country

(yyyy/mm) 34. Employer's name

(yyyy/mm)

31. State

35. Street Address

32. Postal/Zip Code

Apt. No.

To:
37. Colonia/Neighborhood

38. Country

39. State

40. Postal/Zip Code

CBP Form 823S (07/05)