EFTA00316417.pdf

ON-LINE VISA APPLICATION FORM 20002 \ 24.05.2018 22:03:53 Consulate General of Russia in New York 1. Nationality (if you formerly had UNITED STATES USSR or Russian citizenship, please indicate when and why you lost it). 2. Surname (as in passport). EPSTEIN 3. First name, other names, patronimic JEFFREY EDWARD (as in passport). 4. Oate of bir;th (dcymm/yyy . 20/01/1953 5. Sex. MALE 6. Passport. Type of passport: ORDINARY Passport NO: Issued by: UNITED STATES DEPARTMENT OF STATE Date of issue: 23/05/2016 valid until: 22/05/2026 7. Purpose of visit. BUSINESS 8. category and type of visa. COMMON BUSINESS 9. Number of entries. MULTI 10. bate of arrival and departure. 24/07/2018 - 28/07/2018 11. Host organisation you intend to visit. Company name: ASSOCIATION OF NONGOVERNMENTAL PENSION FUNDS TIN: NONE Invitation No: NONE Directive NO: NONE Address: 2 ISVETNOI BOULEVARD, MOSCOW, RUSSIA 127051 12. Route of journey (destination MOSCOW, SAINT-PETERSBURG points). Photograph and signature. Service information (automatically generated). Application form recipient: Consulate General of Russia in New York Basis (voucher, dir. No, inv. No): NONE The estimated date of visit to the RC: Place for Application No (web-site): photograph The date of processing: 5/24/2018 Application NO (VAC): The date of processing by the VAC: Request NO in Russian Consulate (RC): I hereby agree to the processing and transfer of my personal data in electronic form for the purposes of making a decision on visa issuance. I declare that data provided in the application form are full and correct. Date (dd/mm/yyyy), personal signature am aware that any false information may be a cause for the denial of visa or for the cancellation of the previously issued visa and may lead to other consequences provided for by the legislation of the Russian Federation. Subject to the receipt of visa, I pledge to leave the territory of the Russian Federation before the visa expiration date. I am aware that valid visa does not automatically allow to enter the territory of the Russian Federation. In case of denial of entry, I will not seek any compensation for potential losses. Page 1 of 4 EFTA00316417 13. Your permanent address, telephone 6100 RED HOOK QUARTER, 83, ST. THOMAS, USVI 00802 number, fax number, E-mail. 14. Current/latest place of work. SOUTHERN TRUST COMPANY, INC., CHAIRMAN, 6100 RED HOOK QUARTER, 83, ST. THOMAS, USVI 00802, TEL: 340-77S-252S 15. Information about previous Russian visas. Have you ever been issued a Russian YES visa? When and where? 1) 24/04/2015 NEW YORK, NY, USA 2) 14/03/2012 NEW YORK, NY, USA 3) 01/02/2011 NEW YORK, NY, USA 4) 09/01/2004 NEW YORK, NY, USA IA. who will pay for your trip to and INDEPENDENTLY stay in Russia? 17. Information about health insurance. Do you have health insurance that is NO valid in Russia? 18. other names used in the past NONE (maiden, pen-name, religios., etc.). 19. vour place of tiirifi (if you were NEW YORK, NY, USA born in Russia, please:specity.mhen and which country you emigrated to). 20. Additional information about your relatives. marital status: SINGLE Your father's full name: SEYMOUR EPSTEIN Your mother's full name: PAULA EPSTEIN Do you currently have relatives in NO Russia? 21. Additional information. A visa may be refused to persons who are within specific categories defined by the law as inadmissible to Russia. Your answer yes does not automatically signify ineligibility for a visa. In this case you may be required to personally appear before a consular officer. 21.1. Have you ever been arrested or YES convicted for any offence? Place and date: FLORIDA, USA, 30/06/2008 21.2. Have you ever been afflicted with NO a communicable disease of public health significance or a dangerous physical physical or mental disorder? Have you ever been a drug abuser or an addict? 21.3. Have you ever been refused a NO Russian visa? 21.4. Has your Russian visa ever been NO canceled? 21.5. Have you ever been deported from No Russia? 21.6. Nave you ever tried to obtain or No assisted others to obtain a Russian visa or enter Russia by providing misleading or false information. 21.7. Have you ever overstayed your NO Russian visa or stayed unlawfully in Russia? Page 2 of 4 EFTA00316418 22. Planned place of stay in kussia. Name, birth date, address and phone FOUR SEASONS HOTEL MOSCOW, 2 OKHOTNY ROAD, moScow, RUSSIA 109012, TEL: 7- number of person or hotel in Russia 499-2777100 that you plan to stay with: 23. irifornation about completing the application. Has this application been completed YES personally by you? 24. Additional passport information. Has your passport ever been lost or YES stolen? List all countries which have ever NONE issued you a passport: 25. information about your Pfevious 1) FRANCE, 13/05/2018 trips abroad. 2) FRANCE, 31/03/2018 3) FRANCE, 08/03/2018 4) FRANCE, 21/01/2018 5) FRANCE, 02/09/2017 6) FRANCE, 02/07/2017 7) FRANCE, 11/05/2017 8) MOROCCO, 06/04/2017 9) FRANCE, 30/03/2017 10) SWITZERLAND, 23/02/2017 11) FRANCE, 17/02/2017 12) SAUDI ARABIA, 09/11/2016 13) FRANCE, 07/11/2016 14) FRANCE, 28/10/2016 15) FRANCE, 25/09/2016 16) FRANCE, 10/05/2016 17) FRANCE, 20/02/2016 18) FRANCE, 28/03/2014 19) BAHAMAS, 29/10/2014 20) FRANCE, 10/02/2014 21) NORWAY, 28/11/2013 22) UNITED KINGDOM, 18/10/2010 23) TURKEY, 09/11/2010 24) UNITED ARAB EMIRATES, 09/08/2011 25) UNITED ARAB EMIRATES, 04/11/2010 26) RUSSIAN FEDERATION, 22/11/2002 Page 3 of 4 EFTA00316419 26. List your last two places of work, excluding the current one. 1) Company name: FINANCIAL TRUST COMPANY, INC. Address: 6100 RED HOOK QUARTER, B3, ST. THOMAS, USVI 00802 Your position: CHAIRMAN Telephone number: Your chief's surname: NA Dates of joining and dismissal: 04/1999 - 03/2013 2) Company name: EPSTEIN INTERESTS Address: 457 MADISON AVENUE, NEW YORK, NY, USA 10022 Your position: CHAIRMAN Telephone number: Your chief's surname: NA Dates of joining and dismissal: 01/1991 - 01/2013 27. List all educational institutions you ever attended, except high schools. 1) Name: COOPER UNION Course of study: PHYSICS Address and telephone number: 51 ASTOR PLACE, NEW YORK, NY, USA, 212-353-4195 oates of admission and graduation: 09/1969 - 05/1971 28. Special training and experience. DO you have any specialized skills, NO training or experience related to fire- arms and explosives or to nuclear matters, biological or chemical substance? 29. List all professional, civil and 1) TRILATERAL COMMISSION charity organizations which you are/were a member of or 2) HARVARD UNIVERSITY cooperate/cooperated with. • 3) THE EDGE GROUP 30. Military service. Have you ever performed a military NONE service. 31. Arraed conflicts. Nave you ever been involved in armed NONE conflicts, either as a member of the military service or a victim? Page 4 of 4 EFTA00316420