Form DS-0158 Contact Information and Work History for Nonimmigrant Vi

U.S. Department of State

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

OMB APPROVAL NO. 1405-0144
EXPIRES: xx/xx/xxxx
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 Province, Postal Zone, and Country)

5. Full Name and Address of Spouse (If Applicable) (Postal box numbers are unacceptable.)
Name (Last, First, Middle)

Telephone Number

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

Relationship

Address

Telephone Number

Name (Last, First, Middle)

Relationship

Address

Telephone Number

Name (Last, First, Middle)

Relationship

Address

Telephone Number

Name (Last, First, Middle)

Relationship

Address

Telephone Number

Name (Last, First, Middle)

Relationship

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)

Telephone Number

Telephone Number

Address
Name (Last, First, Middle)

Telephone Number

Address

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: A/GIS/DIR, Room 2400, SA-22, U.S. Department
of State, Washington, DC 20522-2202.
DS-158

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Work Experience - Present
Job Title

Date (mm-dd-yyyy)
From

Date (mm-dd-yyyy)
To

Employer's Name and Address
Telephone Number
Describe Your Duties

Work Experience - Previous
Job Title

Date (mm-dd-yyyy)
From

Date (mm-dd-yyyy)
To

Employer's Name and Address
Telephone Number
Describe Your Duties

Work Experience - Previous
Job Title

Date (mm-dd-yyyy)
From

Date (mm-dd-yyyy)
To

Employer's Name and Address
Telephone Number
Describe Your Duties

Work Experience - Previous
Job Title

Date (mm-dd-yyyy)
From

Date (mm-dd-yyyy)
To

Employer's Name and Address

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)
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