EFTA00310414.pdf

VISA APPLICATION IMPORTANT! Please type or print using ballpoint 71 declare that date supplant-Foyme is correctrt ompletc. I am aware that any false statements will 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 I undertake to leave the territory of the Russian Federation upon the expiry of the visa, if granted. I understand that possession of a visalaw. does not entitle its bearer to enter Russia. I will not seek compensation if I am refused to enter Russia . not to be filled 6y holders of diplomatic and official pass • oft 1. Nationality(s you lorsibbidUSSR re Rissonoliterario Praia eataW aadtytoo nn e) Iftlnittb USA 7. ory of visa Last names arum) e InIstYs" BUg 2. S. Number of *stria EPSTEIN Cfst and middle names (at sramr Snots tatty Leyte of Russia n Dottie entryD Multiple entlylEl p JEFFREY EDWARD entr y M 10. Date of departure from Russia 4. Dina 0.0) of birth 20/01/53 18 01 11 omits 18 01 12 (atm .11• Pant*fifti 469911707 Dote of Issue (estrany) 27/05/10 Issued by US DEPARTMENT OF STATE Valid until (5oaem) 26/05/20 12. Type of passport dpiornabc n official Er — tourist dear ri pleasespecify 13. Russian institution or organization to bo visited? On urns-Tweed whomranted Os Wane coppery.* Owns-en - P-te Ci ti e ?Mg teganantead toothre — . more - Liu sane. Can needeatenes and knit Ohtani bebop) I MOO 131,1M1101, MOCKBA 14. Itinerary(Mceicrist) MOSCOW n1fi. Do you have a medical Insurance valid in Russia? yes E nem Weal? UNITED HEALTHCARE 10. Who will pay for your trip to and stay In Russia? no a_ SELF 17. fibrital status married O simple (never married) [:l aborted Enseparated n widowed O. ie. Sousa fun name (nerarotoir sersaled euseistassailassamespetera) I,9. Spouse's date of birth 20. Spouays place of birth ...„„,„ ^21. Your lather's full awns SEYMOUR EPSTEIN 23. Have you ever been issued a Russian vies? Meat and ewe) ,PAYarrg5stu-Pgill YES 2002 NYC, 2003 NYC, 2004 NYC 2006 NYC, 2007 NYC **24. as your passport ever boon lost or stolen? yea no "26. List all countries you have visited In the bet ten years and indicate pasport "26 list all COLIntriPS whlnh have ever issued you • the year of visit ENGLAND,FRANCE,SPAIN,GERMANY, USA RUSSIA,SWEDEN,CZECH REPUBLIC, GREECE,THAILAND,INDONESIA,CUBA ;•27. List your wt two phr ea of work, excludin the currant one 1.thime EPSTEIN INTERESTS Phone rifler 2127509895 Address 457 MADISON AVE Your deers surname NEW YORK, NY 10022 SELF "LE P°Sl. on CHAIRMAN Data of joining-dismissal 1991 own)Present b-mo 2. Name FLORIDA SCIENCE Phone number 5613660084 Address 250 S.AUSTRALIAN AVE Your chiefs surname INDYKE W PALM BEACH,FL 33401 Y°t% "LelPRESIDENT Dales of bainkig - (Own"' 2007 (—n)Present own) EFTA00310414 " • not to be filled by holders of diplomatic and official passports "29. List as educational institutions you ever attended, except high =hoes Name Addles* and phone number COOPER UNION 51 ASTOR PLACE NYC 212-353-4195 Cann' study PHYSICS Dates of admission and graduation 09/69 oinyi)1971 Dkjoirqf 2. Name Address and phone number Cowls of study Dales of admission and graduation : "29.. List all professional. civil and charity organizations which you are I "30. Do you have any specialised skills, training or experience were a member of or cooperate I coopenartd with related to Oro-eons and explosives or to nuclear matters, biological or chemical substance? If yes, please specify IRILATEIRAL COMMISION,HARVARD, NO THE EDGE GROUP "31. Have you ever performed a meaty service? If yes. Indicate the country. branch of soma" mnk IMUWy occupation end dates of ..mc. NO "32. Haveyou ever been Involved in en armed contacts, either as a member of the military service or • victim? If yes, please specify NO 33. IMPORTANT, EACH APPLICANT MUST READ AND GIVE ANSWERS TO THE FOLLOWING QUESTIONS A visa nay ha refused to persons who we within specific categories defined by the her ee ladasslat to Russia. Have you been arrested or convicted for any offence? Y Mail? Wats) 06/29/07 omen? FLORIDA,USA no O Have you ever been afflicted with a communicable dome of public health aignIfIcanoo or • daagorous physical or montalyes repil disorder? Have you ever been a drug abuser or a addkt? 0 Have you over been Mused a Russian Wes? ye0 Whin? (Wown) Where? no0 Has your Russian sin ever been canceled? yeCi Mien? (ddevarly) Where? no© Have y u over tried to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false InfonnetIon? yap noIlg Have you ewer overstayed your Russian vies or stayed unlawfully In Russia? yesfJ no© Have you ever berm deported from Russia? yel.0 When? items' y) Where? n0E] Your answer yes In goon 33 does not automatically signify Ineligibility for a visa. In this case you may be rsqulred to personify appear before a consular officer. 34. Nana d dp cher of a person or hotel in Russia that you plan to stay with 4 NEGLINNAYA ST MOSCOW 109012 35. Has this application been complstad persona/1y by you? h no. Indian the anon coin 3MiTeirximi4611660Rangirtiftir" ST. THOMAS, USVI 00802 Pace for phofograpn 340-775-2525 39. Place of birth (Stan ri eutsia. den. wastage aid mit moray you axioms re) NEW YORK, USA 40. Place of work or study, present position Oars mums flow and to runes En.a0 I agree to my personal dale on this application term wins pnxassad and communicated to the FINANCIAL TRUST COMPANY 340 775 2525 sapwood/a Russian authorides for the Issue of 6100 RED HOOK QUARTERS E33, ST.THOMAS USVI 41. An any of your relatives staying In Russia now? Oats (ostrntyy), applicant's signature raw,meal ticra. di% 01can PriningIC schwa) NO EFTA00310415