Fillable CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA (ILW.COM)

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CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA (ILW.COM)

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5. Full Name and Address of Spouse (If Applicable) (Postal box numbers are unacceptable.)
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
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)
3. Place of Birth
Country
City/Town State/Province
DS-158
10-2009
OMB APPROVAL NO. 1405-0144
EXPIRES: 10/31/2012
ESTIMATED 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 burden and recommendations for reducing it to: U.S. Department of State (A/GIS/DIR) Washington,
DC 20520.
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
Telephone Number
Relationship
Telephone Number
U.S. Department of State
4. Permanent Home Address and Telephone Number (Include Apartment Number, Street, City, State or Province, Postal Zone, and Country)
Name (Last, First, Middle)
Address
Telephone Number
Relationship
Address
Telephone Number
Relationship
Name (Last, First, Middle)
Address
Telephone Number
Relationship
Name (Last, First, Middle)
Address
Telephone Number
Relationship
Name (Last, First, Middle)
Address
Name (Last, First, Middle)
Address
Telephone Number
Name (Last, First, Middle)
Address
Telephone Number
Name (Last, First, Middle)
Address
Name (Last, First, Middle)
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.
DS-158
Page 2 of 2
Date (mm-dd-yyyy)
From
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)
Telephone Number
Telephone Number
Telephone Number
Telephone Number
Employer's Name and Address
Employer's Name and Address
Employer's Name and Address
Describe Your Duties
Describe Your Duties
Describe Your Duties
Employer's Name and Address
Describe Your Duties
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CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA (ILW.COM)

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Completed 9 January 2021

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