Form Ds-158 - Contact Information And Work History For Nonimmigrant Visa Applicant - 2006 Page 2

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Work Experience - Present

Job Title

Date (mm-dd-yyyy)

From

Employer's Name and Address

Telephone Number

Describe Your Duties

Work Experience - Previous

Job Title

Date (mm-dd-yyyy)

From

Employer's Name and Address

Telephone Number

Describe Your Duties

Work Experience - Previous

Job Title

Date (mm-dd-yyyy)

From

Employer's Name and Address

Telephone Number

Describe Your Duties

Work Experience - Previous

Date (mm-dd-yyyy)

Job Title

From

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.

Date (mm-dd-yyyy)

Applicant's Signature

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DS-158