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. 1405-0144
EXPIRES: 04/30/2019
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: PRA_BurdenComments@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, 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.
Confidentiality Statement
dd mmm yyyy
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 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)
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)
dd mmm yyyy
dd mmm yyyy
click to sign
signature
click to edit
dd mmm yyyy
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