is VISA APPLICATION IMPORTANT! Please type or print using ballpoint ‘1 declare that date supplied by me is correct and complete. | am aware that any false statemenis will lead lo my application being rejected or to the annulment of a visa already granted and may also render me liable to prosecution under Russian law. | undertake to leave the territory of the Russian Federation upon the expiry of the visa, if granted. | understand that possession of a visa does not entitle its bearer to enter Russia. | will not seek compensation if | am refused to enter Russia. ** = not to be filled by holders of diplomatic and official passports 41. Nationall had USSA or Russian Pease indicate when and why you lost i Ny Crmenen mee ’ | BUSINESS U Ss A 7. Category and type of visa | BUSINESS _ “2. Last name(esin passer) 6. Number of entries EPSTEIN Single enty [—] Double entyf _] Mutiple entry[<] 3 JEFFREY EDWARD | | dee 10. Date of departure from Russia “Gon 20/0153 |) FET 118 01 14 mmm) 18 01 12 (otemmy 11. PassportNo 469941707 Date of Issue (mn) 27/05/10 | Issued by US DEPARTMENT OF STATE Valid until (ddtmmyy) 26/05/20 12. Type of passport ”__ diplomabe | official Cc] tourist | other Cc] please specify 43. Russian institution or organization to bo Visited? (icc juste - name and releronce number ol @e boul onal Company. for busnesumen - name of the Dost organaaen and town. for private persons ~ asi name. frst name maddie names and home address of the host) MOO BbIMNEN, MOCKBA 14, Minerary (places of vot) - MOSCOW **16. Do you have a medical Insurance valid in Russia? ves [X] Pease speciy? UNITED HEALTHCARE | 16, Who will pay for your trip to and stay in Russia? SELF 17, Marital status mamied [| single (never married) [YX] divorces [~] separates [widowed i ~ | 18, Spouse's full name (ievortedor separaled please indcote marden name il appicaie) 19. Spouse's date of birth 1 {(durwnyy) 20. Spouse's place of birth “21. Your father’s full name 7 | “*22. Your mother's full name - SEYMOUR EPSTEIN | _ PAULA EPSTEIN 23. Have you ever been issued a Russian visa? (When and wee?) 4] YES 2002 NYC, 2003 NYC, 2004 NYC 2006 NYC, 2007 NYC | “24. Has your passport ever been lost or stolen? - yes T Pepi ——— you have visited in the last ten years and indicate | “26, List all countries which havo ever issued You # passport — | ENGLAND,FRANCE,SPAIN,GERMANY, | USA RUSSIA,SWEDEN,CZECH REPUBLIC, | | GREECE, THAILAND, INDONESIA,CUBA | | "27. List your last two places of work, excluding the current one a : | |1. Name EPSTEIN INTERESTS Phone number 2427509895 NEW YORK, NY 10022 SELF | | Your positon CHAIRMAN ; __Dates of joining dismissal 1991 (nm) Present (men) 2. Name FLORIDA SCIENCE Phone number = 5613660084 7 | Address = 250 S.AUSTRALIAN AVE Your chiefs sumame INDYKE W PALM BEACH,FL 33401 | |_YoursostomPRESIDENT Dates ofjoining~ dismissal 2007 (mn) Present em EFTA00310414

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** ~ 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 212-353-4195 ' Course of study PHYSICS Dates of admission and graduation 9/69 _— (ewvyy) 1971 Dor ws) | 2.Name 7 Address and phone number -— ~ | Course of study Dales of admission and graduation (remy) (inmyy) “*28. List all professional, civil and charity organizations which you are / | **30, Do you have any Specialized skills, training or experience were a member of or cooperate / cooperated with related to fire-arms and explosives or to nuclear matters, biological or chemical substance? Hf yes, please specify TRILATERAL COMMISION,HARVARD, NO THE EDGE GROUP “31, Have you ever performed a military service? If yes, indicate the country, branch of service, rank, military ‘occupation and dates of service “*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 — NO 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. _ i Have you ever been arrested or convicted for any offence? yeq X] When? (ssnmy) 06/29/07 Where? FLORIDA,USA nof | i inicable di; f my us | pad pork Have you ever been a drup abuser — Sen of public health significance or a dangerous physical or montates|~ | nof X] Have you ever been refused a Russian visa? yeq | When? (6am) Where? no [X] Has your Russian visa ever been canceled? ~ ” j yet | When? (ddimnyy) Where? nop] Have you ever tried to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false information? yes Cc] ne Have you ever overstayed your Russian visa or stayed unlawfully in Russia? yes. | no[ ><] Have you ever been deported from Russia? : yesf_] When? (cerry) Where? i _ ; . no 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. HM. Name, add, RTPA TER of 8 person or hotel in Russia that you plan to stay with 4 NEGLINNAYA ST MOSCOW 109012 35, Has this application been completed personally by you? If no, Indicate the person completin this - TSu6100 RED HOOK SUITE 83" ST. THOMAS, USVi 00802 Peco photograph 340-775-2525 39. Place of birth (loom in Russia, please indicate whon and what country you emigrated tn) NEW YORK, USA 40. Place of work or study, present position (name, address, phose and fax senders. E-mail) tage omy personal ain on is woteaton | FINANCIAL TRUST COMPANY, 340 775 2525 form being processed and conmuncateétoie | 610) RED HOOK QUARTERS B3, ST. THOMAS USVI visa. 41, Are any of your relatives staying In Russia now? Date (acmmyy), applicant's signature | (fell name, retavon degree, Gate OF bith, permanent address) NO EFTA00310415