EFTA00311310.pdf

1. flporkoe/Famlly name Epstein 2. Itor/lirst name Jeffrey 3. I uss iM€Hu, nponimm, y Thai May laseorae/Other names and (or) maiden name NA larryworxi/male Drascrw/female 5. Ara nalkloadwar/Date of birth 20 01 1953 day II month I year 6. Nertha HapataK3HHO/Pla0e of bath USA .. rapatl/ory Now York roma/country uoranaatb (0athr)/re9I00 NIMO.5111C • - 7. t.pinepawsse(ui) rparepasscrea(B)/Current dtizenship(s) American Kan( 6b1 htftfOlfg Cce)94/13BarTIM(bl), Hanka rpamaASsulatliKko. •004(4) earn0(I) 9 Sac pane*, I mane All7Y04 man) amens/If you changed your cin zenship(s) specify dtizenship(S) you held preAously and indicate dates of the change NA 8. Thin naturiaprarype of passport autisarami/ordinary punnarrattaNHia/dipkmatic drpthareafficial IMwu parymergather document: 9. Hymap natunapra/Passport number 518923892 10. l6meelliaMemi/ISsuing authority USA Dept of State 12. Aare Obiaa414Date of Issue 30 06 2014 day mo i Ljk htl year Craraapumak/Photo sy artOODIR aa3HaHl/ For official use Aim asaperry: K arceions riaunapr 0 /Cue' IllorOmPa' 0 ObiaKAM cat/ 3 Mauritz 3 laraam'a 13. Thous loestrts/Valki until 29 06 2016 IL AM mutaawriPlace of Issue USA 14. Mpac cranara necua sworapc-makennanent home address kpaisakototy USA mmacky St. Thomas 6100 mosavomaiblidnulumbqv wrap nnethona/prione numberaW St I rr t iL onth so6nacutom,ivregion US Virgin Islands synigai street Red Hook Quarters Wel) reararta/apartment nwnbtr 13-3 e-mail JeevacatIon@gmall.com .,Neata npaus I cnyar6oaka o and work address npaarobiennsakomeny Southern Trust Company (STC) nacamiposition President soefecb(pabonegico US Virgin Islands sysiwystred Rid Hook Quarters, B-1 Egret) nnethona/phone number v.:me/conty USA rcoaadty St. Thomas HYna040Bra/budding number 6100 16. Kararopto acm/Cateyuy of visa iM MffiasarlifirouP 17. Tan eau/Type of visa 16. Komaraarb yeapay/Number of entries Drpthermas/transit Drapontarymbotlas/short-temi nagyramprrin0eas/long -tern aPsapaarates/singie Paripaioaargdouble wmarpaaosasimultiple viral 4301)114R Blur/Term of vna validity 3/from 15 08 2014 01 09 2014 na/until year day month year Ha iambi maxothscamm/ for a term of stay 18 days 20. Hama aanpawayi.rall aprastamoil ado it4A sanpawameit acoos/Name of inviting organisation or person nd Fedor Choullak 21. Atac aanpawaromk apraBbauta a6o aco6w/Address of inviting organization or person 606naaw (pat,„ io nw . gBelarus Brksa/street . _ !Irma rearapWaparbnent number synap cpaxca/fax member NA 22. Apra maxcroarota y Senapyci/Address of stay In Bela rus eo6naaMpaesyregto BelarUS syniu,goreet intematsionalnaya IffiraP maraps/apartment number NA 23. nappa6aanae urymeorme 'em Wary/Detailed explanation of a purpose of visit Visting a sick friend ropaacity Minsk Wks) Aonallding number. • wimp minter a. e-mail romp/city Minsk was/ adma/busding number ;8 . racy-Boa/hater Europe Hotel Minsk Pa carry: aa c butane it aucriaoa un rte: U B ▪ C U D Mn. sign: 0 Hach o alalf. cracraa CI men y mama:-.J./ ayraTypea meacanacraaa orb o fraseralaama U melt Sea cfacy.4 n a tuna+ rasa. re Hazr.,-; o Me CYallot unarm o carts o aareona.a. tin: Nr C. Matala• a: na rota* 110/1.1.110, 00 C20111401114 clop: EFTA00311310 nom NA now NA NA lora sorry/purpose of visit 25. flannwasin el3tIbt 9 P3ary6riEy Eeriapycb Ha npatary 6nrymara roma i arynaina 'OWN Hateara 3texowKamo/Rrevious stays iel the Republic of Belarus within a current year and the aggregate tarn of temporary stay 0 3/from NA no/t w NA 4) 3/from NA na/until NA aryntand r3pHIH vacoeara 3143304:4(3/001/ the aggregate term of temporary stay NA 2) 3/hoe no/unoi NA 5) 3/from NA no/until NA NA NA NA NA NA 3) 3/frorn na/unfit 6) 3/from nafiritil ... days 26. la WHO Elam aaKojonema 9 feriapyozal slae a6o Bin &Ina aHyrinaaHa/Have your BelaruSian visa request been ever refused or your visa was cancelled Crax/yes ID a Kani rail, abonagge stalyfif YeS, SPecify the date NA 27. • rani cramoihibi nrearadelan your 11; n-appaslani Have you taK/Yes raK, abonaHtte =al presence ever 0 brapelo is Bu naaHac paHeAuara 3Haxcasaian Ha rapbrropen Pany6nad Eenapyce nu amaranth as napyuswhe fenapyaara 3aKaHadaycrea/ been charged with violating tic Belarusian law while in Belays He/no Kanlfif yes, specify when NA i Azetand where NA ._ Ha marawe He li fia3e pa afaanKosart unions 9 twifiambi abia, 13411433 y e3Tbil airway nmagaHa Ilawa origins nraymaah. 3 lotraH 3 KoncyrbcKikt pafxm4iKat/Rositive arswer will not necessarily affect negatively the considerabon of a visa request, but in this case requested for an interview with a consular officer 20. la 6hini Bui aanaptaaambi 3 sitoi*He6wsae Kpaimhi/Have you ever been deported from any country CI Tar/yes CI Hein Kanl The, nkumavue icanl/if yes, spedfy when NA i 3 nozoil KpaiHm/and from which country NA 29. Tpapicnagnei cpcoaK, rod rpaayrnaaaws am tedaY 9 R3cm6no(Y BeflaiNoil Means of tmnspo-t available for your entrance to the Republic of Belans Boeing 727 Private Plane, TaillN908JE 30. Mapwpyr pyxy/Itinerary Boeing 727 Private Kent Tall MAME. SfayM g me HON Europa Minsk. Vishkig sick friend, 31. 5 LIAaidoxotai Cpaai aa losasammi rabuac 3maxo(tHaHHA 9 Prnyfoltibi Senapych/ Means available for stay In the Repubbc of Beams Hasrittbni cpolutlicash O6armatacix Had/bank cheques t(P3nanwin KaPlitl/aedit cards O3133p0THbl finer/return ticket teKl/travel cheques Onpa*KmaitHe/accomrnodabon 32. 3aecnd a6 Aar-anew matuubmocara apaxasama/Meclical insurance information apaxaeaK apraHl3awia (Hama, aapacodnedxmyinsurance company (name, address, phone) United Healthcare PO BOX 740800, Atlanta, GA canpaciais 3/valid from 01 11 2004 naur:ii NA 33. Csieteinee MI craHoauva/Maital slabs 3Haxabina 9 wr06e/rnanied S He awxnexya 9 wao6e/Sincfie • pamemeHu(a)/divorced OYAasal (yRaea)/widow(er) 34. flpo3siwya mrica (icalid)/Spouse's family name NA 35. flpo3nlimm twata (wood) now Hapaammi/Spouse s last name by birth NA 36. IAA I 'Nairn alba innKa (Koind)/Spotse's first and other names NA 37. fpamaasuicrea(H) riria (zotai)/Spouse's citizenship(s) NA 38. /lam I-abaci:Kama Hpia Oicowd)/ spouse's date of birth 39. Meow HaPaate3HHA myna (Hand)/Spouse's place of birth NA NA Kpama/country rOMOICRY aodnacla, (PaeH)/reglon NA MA day I month if year 40. Kani Bac cynpaaawKaote, mad i woe ysecetisyBatu natriam, 3anoyitie taranigyflf you are accompanied by chidren and they are included in your passport fill In the table below 0143eiwkia/Family name Dal/First Name Ara I Kerma hal*Paifts/Date and place of birth NA NA NA NA NA NA NA NA NA 41. AaNnapaquo/Dedaration A 3a49nsio, urro nictopmaubist, MR 3mewLiana 9 rani; airkeue, a'n9neeteta Rama/pia I npa9µ3teail. A seam, urro naseaamineene Nenpatmlatax arecrax anu6o aama9neeme ea npaRCra9natitn mea6xowitax Aarryneural Nova crrynatt, naacraeaR Am ausoeta sa teame 9 PicnyGnircy 6enapycb. A rakcama naruiramicamiA, urro, Kani rams liKMPHatlbISI 6yaae ripboiraila neaaxnamaii, aim woke 6sub my:Lemma 9 m06ti momairr. A a6aesoroce na npskautti 9 Pacny6nbcy 6enapycb ea t'cratiotnenbut napaArrY attoPrath paricrpagbuo I naKiiiyua se rspbrrophao Aa aaKaniomin npNiny R3entiHst el3w. Si nannp3micatbi a6 Hea6xoatracul mein, nanvac nae3axi meabruboiceyo crpaxo9Ky, man aahatimae aarcasap,a9c-rey Pacny6nlid 6enapyce / I dedare that Information in this application Is true and correct. I am aware that any false statements or refusal to submit the necessary documents may lead to withholding a permit to enter Belarus. I am also warned that If this Information Is found to be incorrect the visa may be cancelled at any time. On arrival to the Republic of Belarus I vrill register according to the established procedure and leave the territory of the Republic of Belarus before my visa expires. I am aware that during my travel I need to have a medical insurance that corresponds to the requirements of Belarusian legislation. 42. Ara. . nalinic/S/Onattfie 43. Ana nunicaiow/Date of ognabse [04 08 2014 I EFTA00311311 20002.859160218/3/201412:17:18 AM Completed: visa.kdmid.ru Destination: Cumulate General of Russia in New York; V!SA APPLICATION I declare that of data given in this form is complete and true. I am aware that any false statements will lead to my application being rejected or to the annulment of a visa already granted and may also render me fable to prosecution under Russian law. I undertake to leave the territory of Russia upon the expiry of the visa If granted. I understand that possession of a visa does not entitle its bearer to enter Russia automatically. I will not seek compensation if I am refused to enter Russia. " - not to be filled by holders of diplomatic and official passports 1. Nationality(if)°u last Itad USSR ciabas ian atizership Orin Moto when vsliitry toy loll it) UNITED STATES 6. Purpose of visit BUSINESS 7. Category and type of visa COMMON BUSINESS 2. Last name(ase passpcn) EPSTEIN S. Number of entries Single entry . l DoubN entry I . MOO tl i int r Y X . 3. First and middle names (as ii pawn) JEFFREY EDWARD 9. Date of entry in Russia 20/0812014 (dwiwwy) 10. Date of departure from Russia 29/08/2014 (xinnyy) 4. Date of (dtwity) birth 20/01/1953 5. Sox )( F I 11. Passport N° 516923892 Date of issue (flerrnmY1) 30/06/2014 Isbubd by US DEPARTMENT OF STATE Valid until (datnnfiy) 29/06/2016 12. Typo of passport diplomatic I olacial . tourist __. other please specify 13. Russian Institution or organization to be visited? (rar tett -a sedatives:stutterer Peron WV swan. Icr buseesserm - earnest's, hastorotrmstosaid bal. lorry/ale more- us rem.. kit nausea ems am hare addled Ste MO MINISTRY OF ECONOMIC DEVELOPMENT OF RUSSIAN FEDERATION, 1,3 1-YA TVERSKAYA-YAMSKAYA, MOSCOW 14. Itinerary(pacesdestO MOSCOW "15. Do have insurance valid In Russia? HEALTH CARE i you a medical yes Please specify? UNITED . I . 16. Who will pay for your trip to and stay In Russia? Independently 17. Marital status married J single (never married) X divorced separated I widowed J 18. Spouse's full name Winced a separatat pleasSeale resift remellamictu) N A 119. Spouse's date of birth (0,..w) NA 20. Spouse's place of birth 1 A. "21. Your father's full name SEYMOUR EPSTEIN "22. Your mother's full name PAULA EPSTEIN 23. Have you ever been Issued a Russian visa? (Mn ad Mere?) 01/02/2011, USA "24. Has your passport ever been lost or stolen? yes X no I "25. List all countries you have visited In the last ten years and Indicate the year of visit FRANCE, 28/03/2014; NORWAY, 28/11/2013; UNITED ARAB EMIRATES, 09/08/2011; TURKEY, 09/11/2010 "26. List all countries which have ever issued you a passport NONE "27. Ust your last two places of work, excluding the culvert one 1. Name EPSTEIN INTERESTS Address 457 MADISON AVE, NYC, NY 10022 Voir Pillion CHAIRMAN Phone number ornery) 07/2014 (InnYt) Your chrers surname SELF Dates of joining - dismissal 01/2007 2. Name NONE Phone number \Of ,L: AddAeS3 NONE Your chiefs surname NONE Vourpetition NONE Dates of joining —dismissal NONE (ii.ww) NONE (nwn) EFTA00311312 • 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 Course of study PHYSICS Dales of admission and graduation 09.196LI frown 0 Li 971 (rnmYY); 2. Name Address and phone number NONE NONE Course of study NONE Dates of admission and graduation NONE own) NONE *wry) ••29. List ail professional, civil and charity organizations which you are I "30. Do you have any specialized skills, training or experience were a member of or cooperate / cooperated with related to tire-arms and explosives or to nuclear matters, biological or NONE chemical substance? H yes, please specify NONE "31. Have you ever performed a military service? If yes, Indicate the country, branch of service, rank. military occupation and dates of service NONE "32. Have you ever been Involved in an armed conflicts, either as a member of the military service or a victim? If yes, please specify NONE 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 n inadmissible to Russia. Have you ever been arrested or convicted for any offence? yin X. When? (eermw) 20/07/2008 where FLORIDA, US no _ Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mentaces : no • --• disorder? Have you ever been a drug abuser or a addict? Have you ever been refused a Russian visa? yes When? (oMinvyn Where? no ...! Has your Russian visa ever been canceled? yes Mien? (diternr) Where? no X Have you ever tied to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false information? yes H 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? Winery?) 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 number of a parson or hotel in Russia that you plan to stay with phone ARARAT PARK HAYATT MOSCOW, 4 NEGLINNAYA STREET MOSCOW, RUSSIA, 109012, 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 NA . ailliliimilli_— IA lk address 37. Other names ever (neida, My used mme. reno.rne. cream e:.) NONE 38. Your permanent address, p u lit LITTLE ST JAMES, USVI, . Place for photograph 39. Piece of birth (nom n Reset please =bre eel a-d wt,* only p; °royal lo) NEW YORK, USA 40. Place of work or study, present position (nen adcbast pane ad Itoranlart E-rnal) I some to my parsons! data on this raMilcstion N, 6100 RED HOOK SUITE B3, ST THOMAS, form being processed ana communicated o the appropriate Russian a uthoritles for the issue or a visa. Date kiarnvyy). applicant's signature E /6 NJ in Russia now? tuts) 4----- I EFTA00311313