EFTA00311304.pdf

VISA APPLICATION IMPORTANT! Please type or print using ballpoint 'I declare !hut dale suppled is correct an complete. I am aware that any false statements wilt lead to my application being relec 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 the Russian Federation upon the expiry of the visa, if granted. I understand that possession of a visa does not ; Russia. I will not seek compensation if I am refused to enter Russia entitle its bearer to enter •••. not to be filled by holders of diplomatic and official pan • orb 1. Nationety(ryor int RS USSR or Assuanomen* SW redraw WS ad sty piMI A) USA sEratemt Ca type of visa a tegoryIars 2. Last nimbusin arum) a Number of entries EPSTEIN Sngls entry 0 Mutes *MC] Mufti. entry inirst and middle names (aBrpmr0 S. Dote of entry hi Russia 10. Date of departure from Russia JEFFREY EDWARD 4. Data of birth 20/01/53 18 01 11 swim 18 01 12 (atom 11. Passport No 469911707 Dote of Issue Warown) 27/05/10 issued by US DEPARTMENT OF STATE Valid until(earn 26/05/20 12. Type of passport dpiernabc offIclarrn tourist other 0 please specify 13. Russian Institution or organization to be visited? Orrwive - MeelelNene*reetercres Mallailitcoroasy lor basoessren - ',gammonad Lamarpre organ-tainamerya madeeines atenos Cass or heMu) Lk". a ee ?WU MOO BI,M1101, MOCKBA 14.ftineraryouotsano MOSCOW n 16. Do you have a medical insurers.* valid in Russia? Yes Please WSW? UNITED HEALTHCARE 10. Who will pay for your trip to and stay In Russia? no s SELF 17. MarItal status mailed O single (never monied) 0 10. Spouse's fun name (resserlerreprons peasenseisadawieseinelicare) din:ward EFseparsted n „mind 19. Spouse's date of birth (arunvy) 20. Spouse's place of birth —21. Your lather's ha name SEYMOUR EPSTEIN . 7 PAULA EPSTEIN -212y egs r gi I 23. Hove you ever been issued a Russian visa? (west area wane?) YES 2002 NYC, 2003 NYC, 2004 NYC 2006 NYC, 2007 NYC ;natio. your passport ever been lost or stolen? yeses non - 26. all List countries you have visited In the last ten years end Indicate "26. List all countries which have ever issued you a passport the year of visit ENGLAND,FFtANCE,SPAIN,GERMANY, USA RUSSIA,S.WEDEN,CZECH REPUBLIC, GREECE,THAILAND,INDONESIA,CUPA - . List your lest two phroil of work excluding tLNrcuffent 404 "27 1. NOM EPSTEIN INTERESTS Phone number Address 457 MADISON AVE Your thiefs surname NEW YORK, NY 10022 SELF your position CHAIRMAN Dates of jdninp —dismissal 1991 ,,,,,)Present (man) 2.Nrne FLORIDA SCIENCE Phone number - — Address 250 S.AUSTRALIAN AVE Your Wets surname E W PALM BEACH,FL 33401 ThurPoub°"PRESIDENT Dales of joining —dismissal 2007 (—Present 6.1147) EFTA00311304 " • not to bo filled by holders of diplomatic and official passports "26. List all educational institutions you ever attended, except high schools _ T. Name edthess and phone number COOPER UNION 51 ASTOR PLACE NYC Cone or NWT PHYSICS Dates of admission and graduation 09/69 • orwri)1971 Dkjoirqf 2. Name Address and phone number 1 !Corns of study Dates of admission and graduation (teem) (frrmy "23. Ust all professional. ova and charity organizations which you are I n30. Do you have any specialized skills, training or experience ware a member of or cooperate / cooperated with rotated to fire-arms and explosive* or to nuclear matters, biological or chemical substance? N yes, please specify TRILA THE EDGE GROUP I "31. Have you ever performed • mleary emotes? If yes. Indicate the country, branch of service, rank military occupation end date* of *MIMI NO "32. Have you ever been invoked In en armed conflicts, either as a member of the military service or • victim? If yes, please specify NO 33. IMPORTANT, EACH APPUCANT MUST READ AND GNE ANSWERS TO THE FOLLOWING QUESTIONS A visa nay be refused to persons who we within specific categories defined by the ire as inadmissible to Russia. Have you r been arrested or convicted for say offence? Y When? Intowrii 06/29/07 more? FLORIDA,USA no 0 Have you ever been afflicted wen a communicable disease of pubic health significance er a dangerous physical or mentelyes disorder? Have you ever been a drug abuser or a addict? 0 no Have you ever been refused a Russian vies? yecCI When? Grunray) Where? no[j Has your Russian visa ever been canceled? yeiEj Viihen7(satreaey) Whore? no© Have you ever toed to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false ion? infonnet Yu no® Have you ever overstayed your Russian visa or stayed unlawfully In Ruses? yes no Have you ever been deported from Russia? YesEl When?(d iy) where? n0El Your answer yes In item 33 does not automatically signify Ineligibility for a visa. In dde ease you may be required to personally appear before a consider officer. 34. Nemo, d dp Eller of person or hotel in Russia that you plan to stay with 4 NEGLINNAYA ST MOSCOW 109012 35. Has this application been correlated personalty by you? II no, indicts the person completing this efellostion in Item all 36. Application completed: Surname, first name Relationship to ASSISTANT applicant a na 301 E. 66TH ST NYC 10065 37. Other names ever used (- alder-are. x.r-nareIrk {Mat) tg57617767gEri2i6h6kanganItuEnber:3E4" n Pace far photograph I MO USVI 00802 39. Place of birth neon venue Pease safes am and vox county ye.,rifle lo) NEW YORK, USA 40. Place of work or study, present position (one. /dew. plow and to antes Easel) I agree to my personal dale on Oils application FINANCIAL TRUST COMPANY 340 775 2525 fOrM being processed and COIOnlyokatod to the appropriate Russian eutherides for the issue of 6100 RED HOOK QUARTERS 63, ST.THOMAS USVI vino. 41. Am any of your relatives staying in Russia now? Date (marraw), applicant's signature (Id name, newt ewes aniolta. prawn address) NO EFTA00311305