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 entitle its bearer to enter ; Russia. I will not seek compensation if I am refused to enter Russia ••• . not to be filled by holders of diplomatic and official pan • orb 1. Nationety(ryor int RS USSR or Assuan omen* SW redraw WS ad sty pi MI A) USA 2. Last nimbusin arum) EPSTEIN inirst and middle names (a Br pmr0 JEFFREY EDWARD sEratemt a Ca tegoryI ars type of visa a Number of entries Sngls entry 0 Mutes *MC] Mufti. entry S. Dote of entry hi Russia 10. Date of departure from Russia 4. Data of birth 20/01/53 18 01 11 11. Passport No 469911707 Dote of Issue Warown) issued by US DEPARTMENT OF STATE Valid until (earn 12. Type of passport dpiernabc other 0 please specify 13. Russian Institution or organization to be visited? Orr wive - Mee lel Nene* reetercres Mallailitcoroasylor basoessren - Lk". a ee ?WU ',gammonad Lamar pre organ-tai name rya made eines ate nos Cass or he Mu) MOO BI,M1101, MOCKBA 14.ftineraryouotsano swim 27/05/10 26/05/20 18 01 12 (atom offIclarrn tourist 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? SELF 17. MarItal status mailed O single (never monied) 0 din:ward EFseparsted n „mind 10. Spouse's fun name (resserlerreprons peasenseisadawieseinelicare) 19. Spouse's date of birth (arunvy) no s 20. Spouse's place of birth 7 -212y regs gi —21. Your lather's ha name PAULA EPSTEIN SEYMOUR EPSTEIN . 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? - 26. List all countries you have visited In the last ten years end Indicate the year of visit ENGLAND,FFtANCE,SPAIN,GERMANY, RUSSIA,S.WEDEN,CZECH REPUBLIC, GREECE,THAILAND,INDONESIA,CUPA "27 - . List your lest two ph roil of work excluding tLNrcuffent 404 1. NOM EPSTEIN INTERESTS Address 457 MADISON AVE NEW YORK, NY 10022 your position CHAIRMAN 2.Nrne FLORIDA SCIENCE Address 250 S.AUSTRALIAN AVE W PALM BEACH,FL 33401 ThurPoub°"PRESIDENT yeses non "26. List all countries which have ever issued you a passport USA Phone number Your thief s surname SELF Dates of jdninp — dismissal 1991 Phone number Your Wets surname Dales of joining — dismissal 2007 ,,,,,)Present (man) - — E (—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 THE I TRILA EDGE GROUP "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 no disorder? Have you ever been a drug abuser or a addict? 0 Have you ever been refused a Russian vies? yecCI When? Grunray) Where? Has your Russian visa ever been canceled? yeiEj Viihen7(satreaey) Whore? Have youion? ever toed to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false infonnet Yu no® Have you ever overstayed your Russian visa or stayed unlawfully In Ruses? yes no Have you ever been deported from Russia? When?(d iy) YesEl where? no[j no© n0 El 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 d p 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 Pace far photograph I agree to my personal dale on Oils application fOrM being processed and COIOnlyokatod to the appropriate Russian eutherides for the issue of vino. Date (marraw), applicant's signature a na 301 E. 66TH ST NYC 10065 37. Other names ever used (-alder-are. x.r-nare Irk {Mat) tg57617767gEri2i6h6kanganItuEnber:3E4" n 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) FINANCIAL TRUST COMPANY 340 775 2525 6100 RED HOOK QUARTERS 63, ST.THOMAS USVI 41. Am any of your relatives staying in Russia now? (Id name, newt ewes aniolta. prawn address) NO EFTA00311305