Address Telephone Number Address Telephone Number Address Address Address Address Address Relationship 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) 6. Full Names and Addresses of Children, Parents, and Siblings (Postal box numbers are unacceptable.) CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA APPLICANT 1. Last Name(s) First Name(s) Middle Name 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. 2. Date of Birth (mm-dd-yyyy) Country City/Town State/Province 3. Place of Birth DS-158 05-2017 Paperwork Reduction Act Statement 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.) Page 1 of 2 U.S. Department of State OMB APPROVAL NO. 1405-0144EXPIRES: 06/30/2019ESTIMATED BURDEN: 1 HOUR *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 burdenand recommendations for reducing it to: PRABurdenComments@state.gov. Name (Last, First, Middle) Telephone Number Relationship Name (Last, First, Middle) Telephone Number Relationship Name (Last, First, Middle) Relationship Name (Last, First, Middle) Telephone Number Relationship Name (Last, First, Middle) Telephone Number Telephone Number Name (Last, First, Middle) Address Telephone Number Name (Last, First, Middle) 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, orenforcement 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. Confidentiality Statement Employer's Name and Address Describe Your Duties Employer's Name and Address Describe Your Duties Describe Your Duties Describe Your Duties Telephone Number Telephone Number Telephone Number Employer's Name and Address Telephone Number Employer's Name and Address Date (mm-dd-yyyy)From 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 thebest 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. DS-158 Page 2 of 2 Date (mm-dd-yyyy) To Work Experience - Present Job Title Date (mm-dd-yyyy) From Date (mm-dd-yyyy) To Work Experience - Previous Job Title Date (mm-dd-yyyy) From Date (mm-dd-yyyy) To Work Experience - Previous Job Title Date (mm-dd-yyyy)From Date (mm-dd-yyyy)To Work Experience - Previous Job Title Applicant's Signature Date (mm-dd-yyyy)