Free DS-0158 - Federal

U.S. Department of State

CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA APPLICANT
1. Last Name(s)

OMB APPROVAL NO. 1405-0144 EXPIRES: 08/31/2009 ESTIMATED BURDEN: 1 HOUR

Please Type or Print Your Answers in the Space Provided Below Each Item Please Attach an Additional Sheet if You Need More Space to Continue Your Answers First Name(s) Middle Name

2. Date of Birth (mm-dd-yyyy)

3. Place of Birth Country

City/Town

State/Province

4. Permanent Home Address and Telephone Number (Include Apartment Number, Street, City, State or Province, Postal Zone, and Country)

5. Full Name and Address of Spouse (If Applicable) (Postal box numbers are unacceptable.) Name (Last, First, Middle) Address 6. Full Names and Addresses of Children, Parents, and Siblings (Postal box numbers are unacceptable.) Name (Last, First, Middle) Address

Telephone Number

Relationship

Telephone Number Relationship Telephone Number Relationship Telephone Number Relationship Telephone Number Relationship Telephone Number

Name (Last, First, Middle) Address

Name (Last, First, Middle) Address Name (Last, First, Middle) Address Name (Last, First, Middle) Address

7. List at Least Two Contacts in Applicant's Country of Residence Who Can Verify Information About Applicant (Do not list immediate family members or other relatives. Postal box numbers are unacceptable.) Name (Last, First, Middle) Address Name (Last, First, Middle) Address

Telephone Number

Telephone Number

Paperwork Reduction Act Statement *Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. In accordance with 5 CFR 1320 5(b), persons are not required to respond to the collection of this information unless this form displays a currently valid OMB control number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, DC 20520. DS-158 08-2006 Page 1 of 2

Work Experience - Present
Job Title Employer's Name and Address Telephone Number Describe Your Duties Date (mm-dd-yyyy) From Date (mm-dd-yyyy) To

Work Experience - Previous
Job Title Employer's Name and Address Telephone Number Describe Your Duties Date (mm-dd-yyyy) From Date (mm-dd-yyyy) To

Work Experience - Previous
Job Title Employer's Name and Address Telephone Number Describe Your Duties Date (mm-dd-yyyy) From Date (mm-dd-yyyy) To

Work Experience - Previous
Job Title Employer's Name and Address Date (mm-dd-yyyy) From Date (mm-dd-yyyy) To

Telephone Number Describe Your Duties

I certify that I have read and understood all the questions set forth in this form and the answers I have furnished on this form are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in the permanent refusal of a visa or denial of entry into the United States. Applicant's Signature DS-158 Date (mm-dd-yyyy) Page 2 of 2