赴美签证158

U.S. Department of State
CONTACT INFORMATION AND WORK HISTORY
FOR NON IMMIGRANT VISA APPLICANT
PLEAST 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 or province, postal zone, and country)




5. Full Name and Address of Spouse (if applicable) (postal box number unacceptable)
Name (Last, First, Middle)




Address




Telephone Number





6. Full Names and Addresses of Children, Parents, and Siblings (postal box number unacceptable)
Name (Last, First, Middle)



























Address



























Relationship


























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 number unacceptable)
Name (Last, First, Middle)







Address








Telephone Number








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. You do not have to provide the information
unless this collection displays a currently valid OMB number. Send comments on the accuracy of this estimate of the burden and recommendations for
reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520.
DS-158 Page 1 of 2
04-2003
OMB APPROVAL NO. 1405-0144
Expires 04/30/06
Estimated Burdon 1 hour