Form Ds-158 - Contact Information And Work History For Nonimmigrant Visa Applicant - 2013

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U.S. Department of State

OMB APPROVAL NO. 1405-0144

EXPIRES: 12/31/2015

CONTACT INFORMATION AND WORK HISTORY

ESTIMATED BURDEN: 1 HOUR

FOR NONIMMIGRANT VISA APPLICANT

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: PRA_BurdenComments@state.gov.

DS-158

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