EFTA00310412.pdf

20002-1103603213119/2015 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 the annulment of a visa already granted and may also render me liable to prosecution under Russian law. of Russia upon the expiry of the visa If granted. I understand that possession of a visa does not automatically. I will not seek compensation if I am refused to enter Russia. to my application being rejected or I undertake to leave the territory entitle its bearer to enter Russia " - not to be filled by holders of diplomatic and official passports 1. Nagonalitowu homely had USSR or RUWall clizenstip. please indcate %hen and why you leo t) UNITED STATES 6. Purpose of visit BUSINESS 7. Category and type of visa COMMON BUSINESS 2. Last name(as in passport) EPSTEIN 8. Number of entries Single entry Double entry Multiple entry X 3. First and middle names (as in passport) JEFFREY EDWARD 9. Date of entry In Russia 24/04/2015 okyrrnyy) 10. Date of departure from Russia 30/04/2015 (thririaryy) 4. Date of (rklarrayy) birth 5. Sex i'll X F 11. Passport No Issued by Date of Issue (ddannnyy) 30/06/2014 OF STATE Valid until (dowiwy) 29/06/2016 US DEPARTMENT 12. Type of passport diplomatic official tourist X other please specify 13. Russian Institution or organization to be visited? (bburial - on end rode ance rumbar of the host Wild =levy. fsr bushessmsn - name of the host alginates and men. {or male pawns-Ian name. IN nano. coddle names and bane address of me I og) FUND ST PETERSBURG INTERNATIONAL ECONOMIC FORUM, SREDNIY PROSPECT 88, BUILDING A, ST PETERSBURG, RUSSIA, 199106 14. Itinerary(piaces 'grist) 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 i 18. Spouse's full name fl imsier separated. please nikale maiden name if applicable) 19. Spouse's date of birth (darnmlyy) 20. Spouse's place of birth "21. Your father's full name SEYMOUR EPSTEIN "22. Your mothers full name PAULA EPSTEIN 23. Nave you ever been Issued a Russian visa? entree ad 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 no _ "25. List all countries you have visited in the last ten years and indicate the year of visit 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 "26. List all countries which have ever issued you a passport UNITED STATES "27. List your last two places of work, excluding the current one 1. Name FINANCIAL TRUST COMPANY Address 6100 RED HOOK, SUITE 83, ST THOMAS, USVI, 00802 Your position CHAIRMAN Phone number 0nmfro 03/2013 (nwry) Your chiefs sumame NA Dates of joining — dismissal 04/1999 2. Name EPSTEIN INTERESTS Phone number Address 457 MADISON AVE, NYC, NY. 10022 Your chiefs surname NA Your position CHAIRMAN Dates of joining - dismissal 00/1991 (rnmhY) 01/2013 (con.) EFTA00310412 " - not to be filled by holders of diplomatic and official passports "28. 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 (urntir) 0011971 (mrIWY) 2. Name Address and phone number NONE NONE Course of study NONE Dates of admission and graduation NONE (my') NONE lam* "29. List all professional, civil and charity organizations which you are 1 were a member of or cooperate I cooperated with TRILATERAL COMMISION; HARVARD; THE EDGE GROUP "30. Do you have any specialized skills, training or experience related to fire-arms and explosives or to nuclear matters, biological or chemical substance? If yes, please specify NONE "31. Have you ever performed NONE a military service? If yes, indicate the country, branch of service, rank, military occupation and involved in an armed conflicts. either as a member of the military service or a victim? If yes. please dates of service "32. Have you ever been NONE specify 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? (deVmmisy) 29/06/2007 Where? FLORIDA no Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or manta e no X disorder? Have you ever been a drug abuser or a addict? Have you ever been refused a Russian visa? yes When? (ddimm)y) Where? no X Has your Russian visa ever been canceled? yes When? (delimrn)y) 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? (ddirnmiyy) 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, 35. Has this application been completed personally by you? If no, indicate the person completing this application in Item 36 yes X no 36. Application completed: Surname, first name Relationship to Applicant's applicant address o the of a 37. Other names ever NONE 38. Your permanent LITTLE ST JAMES, used (maiden name. pennsme. hdy address, phone and fax number. 6100 RED HOOK SUITE n Russia. please indicate Wien and ens' study, present position (name. COMPANY, CHAIRMAN, 00802, relatives staying in Russia now? of birth. perrrenent address) orders. et.) E-mail B3, ST THOMAS, USVI 00802, country you erngretai to) address. phone and faxnurrbers E-rnal) 6100 RED HOOK SUITE B3, Race for photograph 39. Place of birth (If torn NEW YORK, USA 40. Place of work or SOUTHERN TRUST ST THOMAS, USVI 41. Are any of your (Unarm. reign, degree. dale NONE I agree to my form being processed appropriate visa. Date (4ditmvyy), personal data on this application and communicated Russian authorities for the issue applicant's signature EFTA00310413