EFTA00292666.pdf

20002-110360321311912015 9:30:31 PM Completed: visa.kdmid.ru Destination: Visa Application Center ILS (New York); VISA APPLICATION I declare that all data given in this form is complete and true. I am aware that any false statements will lead to my application being rejected or to the annulment of a visa already granted and may also render me liable to prosecution under Russian law. I undertake to leave the territory of Russia upon the expiry of the visa If granted. I understand that possession of a visa does not entitle its bearer to enter Russia automatically. I will not seek compensation if I am refused to enter Russia. " - not to be filled by holders of diplomatic and official passports 1. NatIonality0i you homely had USSR or Rusean cazenshp, please indcle when and why you bat 0 6. Purpose of visit UNITED STATES BUSINESS 7. Category and type of visa COMMON BUSINESS 2. Last name(as in passFor) 8. Number of entries EPSTEIN Single entry Double en ry Multiple entry X 3. First and middle names (as in passport) 9. Date of entry in Russia 10. Date of departure from Russia JEFFREY EDWARD 4. Date of birth 5. Sex X (ddlnmlyy) 20/01/1953 M 24/04/2015 ov,,,,wy) 30/04/2015 (ddrinnilyy) Passport No Date of issue sisistom 30/06/2014 it 516923892 Issued by US DEPARTMENT OF STATE Valid until (ssymbyy) 29/06/2016 12. Type of passport diplomatic official tourist X other please specify 13. Russian Institution or organization to be visited? (for tourists -nuns and reference rumter ol the host tourist company. for businessmen - name ol the host organization and ken. lor pdvale pantos - lasl name. tisl name. coddle names and hone address al die host) FUND ST PETERSBURG INTERNATIONAL ECONOMIC FORUM, SREDNIY PROSPECT 88, BUILDING A, ST PETERSBURG, RUSSIA, 199106 14. Itinerary(places of dui) SAINT-PETERSBURG "15. Do you have a medical insurance valid in Russia? yes x Please specify? UNITED HEALTHCARE no 16. Who will pay for your trip to and stay In Russia? Independently 17. Marital status married single (never married) X divorced separated widowed , 18. Spouse's full name (il dinorced or separated. please iidioste maiden name if applicable) 19. Spouse's date of bIrth (ddimmyy) 20. Spouse's place of bInh "21. Your father's full name n22. Your mother's full name SEYMOUR EPSTEIN PAULA EPSTEIN 23. Have you ever been issued a Russian visa? (Then and where?) 01/02/2011, NYC; 30/10/2006, NYC; 04/04/2007, NYC; 09/01/2004, NYC -- , "24. Has your passport ever been lost or stolen? yes X nol .o "25. List all countries you have visited in the last ten years and indicate n26. List all countries which have ever issued you a passport the year of visit UNITED STATES FRANCE, 00/00/2015; NORWAY, 00100/2013; UNITED ARAB EMIRATES, 00/00/2011; TURKEY, 00/0012010; CZECH REPUBLIC, 00100/2006; VIRGIN ISLANDS, BRITISH, 00/0012013 n27. List your last two places of work, excluding the current one 1. Name FINANCIAL TRUST COMPANY Phone number 3407752525 Address 6100 RED HOOK, SUITE 83, ST THOMAS, USVI, 00802 Your chief's surname NA Your position CHAIRMAN Dates of joining — dismissal 04/1999 ( vs) 03/2013 (nww) 2. Name EPSTEIN INTERESTS Phone number 2127509895 Address 457 MADISON AVE, NYC, NY. 10022 Your chief's surname NA Your position CHAIRMAN Dates of joining —dismissal 00/1991 ism%) 01/2013 (my) EFTA00292666 •• • not to be filled by holders of diplomatic and official passports "26. List all educational institutions you ever attended, except high schools 1. Name Address and phone number COOPER UNION 51 ASTOR PLACE NYC, 2123534195 Course of study PHYSICS Dates of admission and graduation 09/1969 ("nth 00/1971 frornYA 2. Name Address and phone number NONE NONE Course of study NONE Dates of admission and graduation NONE (Irav/I) NONE (r^r^W) "29. List all professional, civil and charity organizations which you are / "30. Do you have any specialized skills, training or experience were a member of or cooperate / cooperated with related to lire-arms and explosives or to nuclear matters, biological or TRILATERAL COMMISION; HARVARD; THE EDGE GROUP chemical substance? If yes, please specify NONE "31. Have you ever performed a military service? If yes, indicate the country, branch of service. rank, military occupation and dates of service NONE "32. Haile you ever been involved in an armed conflicts. either as a member of the military service or a victim? If yes, please specify NONE 33. IMPORTANT! EACH APPLICANT MUST READ AND GIVE ANSWERS TO THE FOLLOWING QUESTIONS A visa may be refused to persons who are within specific categories defined by the law as Inadmissible to Russia. Have you ever been arrested or convicted for any offence? yes X When? (ozmnwy) 29/06/2007 Where? FLORIDA no Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or menaces no X disorder? Have you ever been a drug abuser or a addict? Have you ever been refused a Russian visa? yes When? (ckvmowy) Where? no X Has your Russian visa ever been canceled? yes When? (ckhnowy) Where? no X Have you ever tried to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false Information? yes no X Have you ever overstayed your Russian visa or stayed unlawfully in Russia? yes no X Have you ever been deported from Russia? yes When? (drimmw) Where? no X Your answer yes in item 33 does not automatically signify ineligibility for a visa. In this case you may be required to personally appear before a consular officer. 34. Name, address and phone number of a person or hotel In Russia that you plan to stay with THE ASTORIA, BOLSHAYA MORSKAYA UL., 39, SAINT PETERSBURG, RUSSIA, 190000, 78124945757 35. Has this application been completed personally by you? If no, indicate the person completing this application In hem 36 yes X no 36. Application completed: Surname, first name Relationship to Applicant's applicant address 37. Other names ever used (maden name. penrame. ncly orders. el..) NONE 38. Your permanent address, phone and fax number. Email LITTLE ST JAMES, 6100 RED HOOK SUITE B3, ST THOMAS. USVI 00802. 3407752525 Place for photograph 39. Place of birth (II born n Russo. please indicateatm and %hal co-waryyou errigrated to) NEW YORK, USA 40. Place of work or study, present position (name. address. prone and fax numbers. Erna') I agree to my personal data on this application SOUTHERN TRUST COMPANY, CHAIRMAN, 6100 RED HOOK SUITE B3, form being processed and communicated o the appropriate Russian authorities for the issue of a ST THOMAS, USVI 00802, 3407752525 visa. 41. Are any of your relatives staying in Russia now? Date (dammyy). applicant's signature OA name, relate, degree, dale of binh.pernanent address) NONE EFTA00292667