‘| declare that dats supplied by me is correct and complete. | 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 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 0 enter Russia. ** = not to be filled by holders of diplomatic and official passports 41. Nationall (it you formerly hac USSA or Russian o&zenshe. please inGcate when and why you lost ft) " \ BUSINESS U Ss A 7. Category and type of visa BUSINESS 2. Last name(es in peeseen) 6. Nurnber of entries EPSTEIN Single entry [—] Double entyf _] Multiple enty[<] | ne TEFEREY EDWARD al | [tne nee 10. Date of departure from Russia _ Goon) 20/0153 |S wf] FL) | 18 01 11 unm | 18 01 12 (omy) | “11. Passport ic 469911707 Date of issue (mmm) 27/05/10 Issued by US DEPARTMENT OF STATE Vaiid until (siimmy) 26/05/20 12. Type of passport . diplomabic | i official Cc] tourist ; other Cc] please specify 13. Russian institution or organization to be visited? (icc tourists - name and reference number of the Kosi tows company. ly buuheaumen - mame ol Be how organaace and town. for private persons ~ asi name. frst name. middie mames and home address of the host) MOO BbIMNEN, MOCKBA 14. Itinerary (pleces vst) MOSCOW . **16. Do you have a medical Insurance valid in Russia? — ves [X] Pieasespecty? UNITED HEALTHCARE T: | 16, Who will pay for your trip to and stay in Russia? SELF 18. Spouse's full name (i evarved or separaled please idee marian name i applicabie) = ; 19. Spouse's date of birth {auemmvyy) 20. Spouse's place of birth = : | "21. Your father's fullname | "22. Your mother's full name _ | SEYMOUR EPSTEIN _ PAULA EPSTEIN 23. Have you ever been issued a Russian visa? (When and wee?) YES 2002 NYC, 2003 NYC, 2004 NYC 2006 NYC, 2007 NYC | ——-~ - = | | “24. Has your passport ever been lost or stolen? yes no Cc] “26. List all countries you have visited in the last ten years and indicate “26. List all countries which have ever issued You @ passport the year of visit | 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 : _C™~S@Y Name EPSTEIN INTERESTS Prove nonce 4 NEW YORK, NY 10022 SELF | Your position CHAIRMAN ; _Dates of joining — dismissal 1991 __ (mmm) Present (emmn) 2. Name FLORIDA SCIENCE Phone number 7 | Address = 250 S.AUSTRALIAN AVE Your chief's sumame E W PALM BEACH,FL 33401 | :_YourposionPRESIDENT Dales ofjoining dismissal 2007 — (™™n)Present mm EFTA00311304

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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 nycll ' Course of ‘study PHYSICS Dates of admission and graduationQ}9/69 (em 1971 Diirmn | 2. Name Address and phone number — ! Course of study Dates of admission and graduation (menvyy) (mye) "*29. 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? ff yes, please specify TRILATERAL COMMISION,HARVARD, NO THE EDGE GROUP | “31. Have you ever performed a fe Ee 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 ora victim? if yes, please specify — 33. IMPORTANT! EACH APPLICANT MUST READ AND GIVE ANSWERS TO THE FOLLOWING QUESTIONS | A visa may be refused to persons who are an specific categories defined by the law as inadmissible to Russia. Have you ever been arrested or convicted for any offence e432) When? ame) O6/29/07 whee? FLORIDA.USA of] Hove you ever been afflicted with a communicable disease of public health significance or a dangorous physical or montales| ~~] nof xX] _ disorder? Have you ever been a drug abuser or a addict? , Have you ever been refused a Russian visa? yeq__] When? (samy) Where? no [X] Has your Russian visa ever been canceled? —~ . : j ye] When? (adimmyy) 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 unlawtully In Russia? | no Have you ever been deported from Russia? =, == i yesf_] When? (catemyy) Where? ; no Your answer yes in item 33 does not outomatioaty signify ineligibility for a vies. tn this case you may be required to personally pear before a consular officer. M4. Name, Sar of a posson or etal is Reneia cont yee plow trotep a 4 NEGLINNAYA ST MOSCOW 109012 35. Has this application been completed personally by you? If no, indicate the person a this aagnm in itor 36 yes] no X] | 36. Application completed: Surname, first name Relationship © ASSISTANT a E. 66TH ST NYC 10065 _applicant : [3 hr ae rane rm) TSHETOO RED HOOK SUE BS" nies S”' 00802 Place for photograph | 39. Place of birth meer ae | NEW YORK, USA | IN Place of work or study, present position (name, address, phowe and fix senders. E-mail) {agree lo my penonat cae on is wpteaton | FINANCIAL TRUST COMPANY, 340 775 2525 | Spot tosarsectaerteinacs | 6100 RED HOOK QUARTERS B3, ST.THOMAS USVI 41, Are any of your relatives staying In Russia now? Date (asimny), applicant's signature | (fell nama, rekaton degrve, Gate of bie, peemanent adress) NO EFTA00311305