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Contact Information and Work History For Nonimmigrant Visa Applicant

This document is a form from the U.S. Department of State for nonimmigrant visa applicants to provide contact and work history information. It requests information such as the applicant's name, date and place of birth, permanent address, names and addresses of family members, references in their home country, and employment history including job titles, dates of employment, employer contact information, and job duties for current and previous positions. The applicant must certify that the information provided is true and correct.

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37 views2 pages

Contact Information and Work History For Nonimmigrant Visa Applicant

This document is a form from the U.S. Department of State for nonimmigrant visa applicants to provide contact and work history information. It requests information such as the applicant's name, date and place of birth, permanent address, names and addresses of family members, references in their home country, and employment history including job titles, dates of employment, employer contact information, and job duties for current and previous positions. The applicant must certify that the information provided is true and correct.

Uploaded by

Setia Novandi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as RTF, PDF, TXT or read online on Scribd
You are on page 1/ 2

U.S.

Department of State

CONTACT INFORMATION AND WORK HISTORY


FOR NONIMMIGRANT VISA APPLICANT
1. Last Name(s)

OMB APPROVAL NO. 1405-0144


8 /200
1
9
EXPIRES: 0 /3
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

C
4. Permanent Home Address and Telephone Number I( nclude Apartment Number, Street, ity,

State/Province
State or Province, Postal Zone, and Country)

P
5. Full Name and Address of Spouse (If Applicable) ( ostal
box number s are unacceptable .)
Name (Last, First, Middle)

Telephone Number

Address
6. Full Names and Addresses of Children, Parents, and Siblings P
( ostal 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 number s 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: U.S. Department of State (A/ISS/DIR) Washington,
DC 20520.
DS-158
08-2006

Page 1 of 2

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)
Page 2 of 2

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