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CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA APPLICANT U.S. Department of State OMB APPROVAL NO. 1405-0144 EXPIRES: 04/30/06 ESTIMATED BURDEN: 1 HOUR 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 (inc
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  Telephone NumberTelephone Number Permanent Home Address and Telephone Number (include apartment number, street, city, state or province, postal zone, and country)  Name (Last, First, Middle) Full Name and Address of Spouse (if applicable)    (postal box number unacceptable)  Full Names   and Addresses of Children, Parents, and Siblings   (postal box number unacceptable)  U.S. Department of State CONTACT INFORMATION AND WORK HISTORYFOR NONIMMIGRANT VISA APPLICANT Last Name (s)  First Name (s)  Middle NamePLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEMPLEASE ATTACH AN ADDITIONAL SHEET IF YOU NEED MORE SPACE TO CONTINUE YOUR ANSWERSDate of Birth (mm-dd-yyyy)  Place of Birth CountryCity/Town State/Province DS-15804-2003 OMB APPROVAL NO. 1405-0144 EXPIRES: 04/30/06ESTIMATED 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 torespond 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 theburden and recommendations for reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520. Paperwork Reduction Act Statement1.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)  7. Address Page 1 of 22.3. Name (Last, First, Middle) Address 4.5 . 6. Address   Name (Last, First, Middle) RelationshipTelephone Number  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 correctto 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 denialof entry into the United States. DS-158Page 2 of 2 Date (mm-dd-yyyy) From   Date (mm-dd-yyyy) To  WORK EXPERIENCE - PRESENT Job Title:Employer's Name and Address:Describe Your Duties:Date (mm-dd-yyyy) From   Date (mm-dd-yyyy) To  WORK EXPERIENCE - PREVIOUS Job Title:Employer's Name and Address:Describe Your Duties:Date (mm-dd-yyyy) From   Date (mm-dd-yyyy) To  WORK EXPERIENCE - PREVIOUS Job Title:Employer's Name and Address:Describe Your Duties:Date (mm-dd-yyyy) From   Date (mm-dd-yyyy) To  WORK EXPERIENCE - PREVIOUS Job Title:Employer's Name and Address:Describe Your Duties:APPLICANT'S SIGNATUREDATE (mm-dd-yyyy) Telephone NumberTelephone NumberTelephone NumberTelephone Number
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