Fill and Sign the Charlotte Immigration Court Department of Justice Form

OMB NO. 1115-0210 Application Checkpoint Pre-enrolled Access Lane INSTRUCTIONS U.S. Department of Justice Immigration and Naturalization Service Read carefully -- Failure to follow instructions may require return of your application and delay final action. 1. Purpose of Form. The purpose of this form is to permit individuals to apply to participate in the Pre-enrolled Access Lane (PAL) program for the Immigration and Naturalization Service (INS) checkpoints. disposed of, authorization for that vehicle is revoked automatically. To renew your authorization, you should submit a new application on this Form I-866, 90 days prior to the expiration of your authorization. If your authorization to use the PAL is revoked, you may reapply 90 days after the date of revocation. 2. Preparation of Application. Fill in application in single copy only, by typewriter, or print in block letters using only dark ink. Do not use pencil or red ink. Do not leave any questions unanswered. Mark any question which does not apply to you "N/A." 3. Who can apply. United States citizens and other persons which the Commissioner of INS determines to be eligible to participate in the PAL. Information on which other persons are eligible to enroll in the PAL program may be obtained at the PAL enrollment center. All applicants must reside permanently or temporarily in the United States. 4. Where to Submit this Application. In person, by fax or by mail to the PAL enrollment center. 5. Application. Each person wishing to enroll in the PAL must submit a separate application. You should include all vehicle which you wish to register or use in the lane on your application. A separate application may be filed to register additional vehicles any time after the initial application has been approved. Your application must be supported by documents establishing identity, citizenship or lawful immigration status in the United States, a valid driver's license, and vehicle registration for all vehicles being registered. PAL enrollment center staff may require you to submit written permission from the vehicle owner to use any vehicle not owned by you in the lane. You should provide copies of all supporting documents when you file your application. If you file your application in person, you should present original documents for inspection at that time, and you may be requested to bring them to your interview as well. If you file your application by mail, do not send original documents. If you apply by fax, then you must re-sign the application in person at the PAL enrollment center at the time of your interview or at a time indicated by the Pre-enrolled Access Lane enrollment center staff. Present original documents for inspection at the time of your interview or at such time as the enrollment center staff indicates. You may apply to use more than one vehicle, and you may apply to use a vehicle authorized for use in the lane by another person. 7. Use of the Lane. If your application is approved, you will become an enrolled user of the PAL, and this registration will permit you to use the lane only in the authorized vehicle(s) identified on this form. If your application includes a request to register vehicle(s), and the application is approved, those vehicle(s) will be authorized for use in the lane. Other persons may also apply for authorization to use your vehicle(s) in the lane. At least one person authorized to use a specific vehicle in the lane must be in that vehicle when it is used in the lane. 8. Denial. An application to use the PAL may be denied by the Chief Patrol Agent with jurisdiction over the enrollment center. All applicants denied use of the lane shall be notified in writing. There is no appeal from such denial. All applicants who have been denied permission to use the lane must wait 90 days from the date of denial to reapply. Applications submitted without the required documentation or which are incomplete shall be returned to the applicant. 9. Privacy Act Statement. The authority to collect this information is contained in section 101 of Public Law Number 104-134. Furnishing the information on this form is voluntary; however, failure to provide all of the requested information may result in the delay of a final decision or denial of your application. All applicants are subject to a check of immigration, law enforcement and criminal justice information databases and records in order to determine eligibility. The principal use of information collected will be to make a determination on your application. Information will be disclosed during the course of the investigation of your eligibility to the extent necessary to obtain information necessary to INS' determination. Fingerprints will be disclosed to the Federal Bureau of Investigation and other State and local government agencies for the purpose of determining eligibility for participating in this program. If the INS discovers a violation or potential violation of law, your information will be disclosed to the appropriate law enforcement authority charged with investigating, enforcing, or prosecuting the violation, including international organizations engaged in the collection and dissemination of intelligence concerning criminal activity. Information may also be disclosed to members of Congress or their staffs who inquire about this application at the request of the person submitting it. 6. Final Approval. Your application will be reviewed and an interview may be scheduled prior to acceptance. Authorization of a person and vehicle to use the lane is valid until two years from the date of approval of the application or until revoked, whichever occurs first. If a vehicle is sold, stolen, or otherwise Form I-866 (08/25/00)Y Form I-866 (08/25/00)Y Page 2 10. Penalties for False Statements in Applications. Severe penalties are provided by law for knowingly and willfully falsifying or concealing a material fact or using any false document in the submission of this application. Also, a false representation may result in the denial of this application and any other application you may make for any benefit under the immigration laws of the United States. 11. Compliance Checks. Checks may be conducted at the PAL to ensure compliance with applicable laws and the conditions of the program . 12. Reporting Burden. You do not have to complete this form unless it displays a currently approved OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about the form, 20 minutes; 2) completing the form, 8 minutes; and 3) assembling and mailing the application, 4 minutes, for an estimated average of 32 minutes per response. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Immigration and Naturalization Service, HQPDI, 425 I Street, N.W; Room 4034, Washington, D.C. 20536. DO NOT MAIL YOUR COMPLETED APPLICATION TO THIS ADDRESS. Application Acknowledgments and Questions 1. Applicant acknowledges and agrees that the applicant's participation in the Pre-enrolled Access Lane program is voluntary and that by applying, he or she gives all the information collected pursuant to Immigration and Naturalization Service (INS) regulations and this form voluntarily. Applicant further acknowledges that he or she is a United States citizen or a member of a class of other persons which the Commissioner of INS has determined to be eligible to participate in the Pre-enrolled Access Lane. Applicant further acknowledges and agrees that he or she will inform the Pre-enrolled Access Lane enrollment center at which he or she filed the application in writing of any change in his or her immigration status. 2. Applicant acknowledges and agrees that he or she authorizes INS to check immigration, law enforcement, and criminal justice information records and databases for information on the applicant and any vehicle he or she applies to register, and authorizes any agency having such information to release it to INS. Applicant further acknowledges and agrees that by submitting this application he or she freely consents to having INS collect his or her fingerprints and submit them to other agencies for this purpose. 3. Applicant acknowledges and agrees to a full inspection by INS of any vehicle he or she applies to register. Applicant acknowledges and agrees that the vehicle(s) identified on this form is/are lawfully owned and registered to him/her, or that he or she has permission from the vehicle owner to use the vehicle(s) in the lane. Applicant further acknowledges and agrees that it is the responsibility of the applicant to give written notice to the Pre- enrolled Access Lane enrollment center, in person or by facsimile transmission, within 24 hours of when the vehicle(s) identified on this form are stolen or within seven days of when such vehicle(s) are sold or otherwise disposed or license plates are changed. Applicant acknowledges and agrees that valid vehicle registration and, if required upon written notice from INS, permission from the registered owner to use the vehicle shall be in the vehicle at all times during use of a Pre-enrolled Access Lane. 4. Applicant acknowledges and agrees that when using the Pre-enrolled Access Lane, he or she may carry passengers 5. Applicant acknowledges and agrees that prior to each arrival at the Pre-enrolled Access Lane, the applicant will make him or herself aware of the contents of the vehicle in which he or she is an occupant and ascertain that transporting all occupants and contents of the vehicle is permissible by law. Applicant further acknowledges and agrees that he or she is subject to all federal, state and local laws regarding the transport of the occupants and contents of any vehicle in which he or she is an occupant in a Pre-enrolled Access Lane and may be liable for any violation(s) of these laws when using a Pre-enrolled Access Lane. 6. Applicant acknowledges and agrees that vehicles approved for use in the Pre-enrolled Access Lane, and all occupants, will be subject to compliance checks at the INS checkpoint by INS, and that all authorized vehicles remain subject to being stopped and occupants questioned during the use of the lane in order to ensure compliance with applicable laws and the conditions for use of the lane. 7. Applicant acknowledges and agrees that if he or she violates any condition of this program, or any applicable law or regulation, his/her authorization to participate in this program may be revoked, and he or she may be subject to other applicable sanctions. Applicant acknowledges and agrees that he or she must comply with all procedures established for use of the lane, including any signs in the lane. 8. U.S. Department of Justice Immigration and Naturalization Service OMB NO. 1115-0210 Application -Checkpoint Pre-enrolled Access Lane who are not enrolled in the Pre-enrolled Access Lane program in an authorized vehicle, but only if the passengers are either United States citizens, lawful permanent residents of the United States, or rightful holders of valid nonimmigrant United States visas. Applicant acknowledges and agrees that this program confers no immigration benefit or status and no substantive or procedural right enforceable in law or equity by any party in any matter. Form I-866 (08/25/00)Y Page 3 OMB NO. 1115-0210 Application -Checkpoint Pre-enrolled Access Lane Check here if you are approved to participate in any of the following: INSPASS Land Border APP INSPASS Airport DCL 1. Full Name: (Family Name in CAPS) (First) (Middle) 2. Other Names Used (Include Maiden Name): 3. Date of Birth (MM/DD/YYYY) : Gender Male Female 4. Place of Birth: (City) (State) (Country) 5. Address: (Street Number, Apartment) (City) (State) (Zip Code) 6. Permanent Address (Street number and name): (Apartment Number) (State/Province/Country) (Zip/Postal Code) (City) 7. Country of Citizenship: 8. Drivers License Information: (Issuing State) (Number) (Expiration Date) 9. Employer: (Address) (Telephone Number) 10. Citizenship and Immigration Status Yes No If not a Citizen, state your Immigration Status: Alien Registration Number: Name on Alien Registration Receipt Card: (First) (Middle) Date (MM/DD/YYYY) and place of most recent entry into the United States Date (MM/DD/YYYY ) upon which authorized period of stay expires Visa Type: Visa Number: Date of Visa issuance: Place of Visa issuance: Expiration Date of Visa: 11. Criminal History: (Please check yes or no for each question) Have you ever been: a. Convicted of a criminal offense? Yes No b. Arrested for any reason? Yes No c. Found to be in violation of any immigration law? Yes No d. Refused admission to the United States? Yes No e. Denied any other immigration benefit, whether you applied for the Yes No benefit directly, or the benefit was sought on your behalf? If yes to any of the above, please explain (use additional paper if necessary). U.S. Department of Justice Immigration and Naturalization Service Are you a United States Citizen? Form I-866 (08/25/00)Y Page 4 (Family Name) Vehicle Identification Number: Vehicle Year: 12. Vehicle information Vehicle Number 1: License Plate Number, State: Vehicle Color: Vehicle Make/Model: Vehicle Owner: 13. CERTIFICATION. I certify that I have read and understand all statements contained in this application. I certify that I have read and understand all acknowledgements in this application and agree to be bound by their content. I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it is all true and correct. I authorize any agency having information relevant to determining my eligibility for the PAL Program to release that information to the Immigration and Naturalization Service. I understand that all information provided on this application may be shared with other government agencies as described in the Privacy Act Statement contained in this form. (Date) (Signature of Applicant) (Telephone Number) 14. SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT. I declare that I prepared this document at the request of the above person and that it is based on all information of which I have knowledge. Print Name: Signature: Date: Address: Owner's Relation to Applicant: Vehicle Identification Number: Vehicle Year: Vehicle Color: Vehicle Make/Model: Vehicle Owner: Owner's Relation to Applicant: Vehicle Color: Vehicle Make/Model: Vehicle Owner: Owner's Relation to Applicant: Vehicle Identification Number: Vehicle Year: Vehicle Number 2: License Plate Number, State: Vehicle Number 3: License Plate Number, State: Form I-866 (08/25/00)Y Page 5 You are responsible for ensuring that only United States citizens, lawful permanent residents of the United States, and/or rigtful holders of valid non-immigrant United States visas are occupants of any vehicle you use, as a driver or passenger, in the PAL.