U.S. Department of State CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA APPLICANT OMB APPROVAL NO. 1405-0144 EXPIRES: 10/31/2012 ESTIMATED BURDEN: 1 HOUR Instructions - 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. 1. Last Name(s) 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 Telephone Number 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 Address Name (Last, First, Middle) Telephone Number Address Confidentiality Statement INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which certifies that the information contained in such records is needed in a case pending before the court. 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/GIS/DIR) Washington, DC 20520. DS-158 06-2011 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Work Experience - Present Job Title Date (mm-dd-yyyy) From Telephone Number Date (mm-dd-yyyy) To Date (mm-dd-yyyy) From Telephone Number Date (mm-dd-yyyy) To Job Title Date (mm-dd-yyyy) From Date (mm-dd-yyyy) To Employer's Name and Address Telephone Number Employer's Name and Address Describe Your Duties Work Experience - Previous Job Title Employer's Name and Address Describe Your Duties Work Experience - Previous Describe Your Duties Work Experience - Previous Job Title Date (mm-dd-yyyy) From Employer's Name and Address 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 American LegalNet, Inc. www.FormsWorkFlow.com