U.S. Department of State
OMB APPROVAL NO. 1405-0144
CONTACT INFORMATION AND WORK HISTORY
EXPIRES: 08/31/2009
ESTIMATED BURDEN: 1 HOUR
FOR NONIMMIGRANT VISA APPLICANT
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
3. Place of Birth
2. Date of Birth (mm-dd-yyyy)
Country
City/Town
State/Province
4. Permanent Home Address and Telephone Number (Include Apartment Number, Street, City, State or 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.)
Relationship
Name (Last, First, Middle)
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
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
Page 1 of 2
08-2006