Get Omb Approval No 1405 0144 Form

U.S. Department of State CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA APPLICANT OMB APPROVAL NO. 1405-0144 EXPIRES 04/30/2006 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. U*S* Department of State CONTACT INFORMATION AND WORK HISTORY FOR NONIMMIGRANT VISA APPLICANT OMB APPROVAL NO. 1405-0144 EXPIRES 04/30/2006 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 2. Date of Birth mm-dd-yyyy First Name s Place of Birth Country Middle Name City/Town State/Province Permanent Home Address and Telephone Number include apartment number street city state or province postal zone and country Full Name and Address of Spouse if applicable postal box number unacceptable Address Name Last First Middle Telephone Number Relationship 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 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/RPS/DIR Washington DC 20520. DS-158 04-2003 Page 1 of 2 WORK EXPERIENCE - PRESENT Job Title Date mm-dd-yyyy From Employer s Name and Address 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. 1405-0144 EXPIRES 04/30/2006 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 2. Date of Birth mm-dd-yyyy First Name s Place of Birth Country Middle Name City/Town State/Province Permanent Home Address and Telephone Number include apartment number street city state or province postal zone and country Full Name and Address of Spouse if applicable postal box number unacceptable Address Name Last First Middle Telephone Number Relationship 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 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.