EFTA00310414.pdf

VISA APPLICATION IMPORTANT! Please type or print using ballpoint 71 declare that date supplant-Foy me is correct rt 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 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 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 lorsibbid USSR re Rissonoliterario Praia eataW aadtytoo nn e) USA 2. Last names arum) EPSTEIN p Cfst and middle names (at sr amr JEFFREY EDWARD 4. Dina of birth 20/01/53 0.0) .11•Pant*fifti 469911707 Iftlnittb 7. e of visa BUg ory InIstYs" S. Number of *stria Snots tatty n Dottie entryD Multiple entlylEl Leyte of entry M Russia 10. Date of departure from Russia 18 01 11 Dote of Issue (estrany) Issued by US DEPARTMENT OF STATE Valid until (5oaem) omits 27/05/10 26/05/20 18 01 12 (atm 12. Type of passport dpiornabc n official Er — tourist dear ri please specify 13. Russian institution or organization to bo visited? On urns-Tweed whom ranted Os Wane coppery.* Owns-en - P-te Ci tie ?Mg teganantead tooth re — . 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? SELF 17. fibrital status married O simple (never married) [:l aborted Enseparated n widowed O. ie. Sousa fun name (nerarotoir sersaled euseistassailassamespet era) I,9. Spouse's date of birth birth 20.Spouays place of SEYMOUR EPSTEIN ,PAYarrg5stu-Pgill ...„„,„ ^21. Your lather's full awns 23. Have you ever been issued a Russian vies? Meat and ewe) YES 2002 NYC, 2003 NYC, 2004 NYC 2006 NYC, 2007 NYC no a_ **24. as your passport ever boon lost or stolen? "26. List all countries you have visited In the bet ten years and indicate "26 list all COLIntriPS whlnh have ever issued you • pasport the year of visit ENGLAND,FRANCE,SPAIN,GERMANY, USA RUSSIA,SWEDEN,CZECH REPUBLIC, ;•27. List your wt two ph r ea of work, excludin the currant one GREECE,THAILAND,INDONESIA,CUBA 1.thime EPSTEIN INTERESTS Address 457 MADISON AVE NEW YORK, NY 10022 "LE P°Sl. on CHAIRMAN 2. Name FLORIDA SCIENCE Address 250 S.AUSTRALIAN AVE W PALM BEACH,FL 33401 Y°t% "Lel PRESIDENT yea Phone rifler 2127509895 Your deers surname SELF Data of joining-dismissal 1991 own)Present b-mo Phone number 561 3660084 Your chiefs surname no INDYKE 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 :Cowls of study "29. List all professional. civil and charity organizations which you are I were a member of or cooperate I coopenartd with Address and phone number Dales of admission and graduation "30. Do you have any specialised skills, training or experience 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? Mail? Wats) 06/29/07 omen? FLORIDA,USA 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 no O Y Have you over been Mused a Russian Wes? ye0 Whin? (Wown) Has your Russian sin ever been canceled? yeCi Mien? (ddevarly) Where? 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 no Ilg yesfJ no© Where? no0 no© Have you ewer overstayed your Russian vies or stayed unlawfully In Russia? Have you ever berm deported from Russia? ye l.0 When? items' y) Where? n0 E] 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 Pace for phofograpn I agree to my personal dale on this application term wins pnxassad and communicated to the sapwood/a Russian authorides for the Issue of Oats (ostrntyy), applicant's signature 3MiTeirximi4611660Rangirtiftir" ST. THOMAS, USVI 00802 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 FINANCIAL TRUST COMPANY 340 775 2525 6100 RED HOOK QUARTERS E33, ST.THOMAS USVI 41. An any of your relatives staying In Russia now? raw, meal ticra. di% 01 can PriningIC schwa) NO EFTA00310415