GADAYHAEUUA DPYKABANDIMEDITAPAME = TO BE FILLED JN BLOCK LETTERS PSCNYBJIIKA BEJIAPYCh THE REPUBLIC OF BELARUS BISABAA AHKETA VISA APPLICATION FORM 1. Mposelursa/Famity name 4. Non/Sex Epstein Soraagnimax/Photo Byenaicd/male 3. Iter IM@Hbt, NDOSBIUEL, Y THM Aly AsABONde/Other names and (or) maiden name CrrypxGoaen ansnani/ For official use Aare saspory: Kani Bei maxi mpamageHcrea(es), ), Hasasliye rpamayarHcrea( ts), ore Geunati) ¥ y _ pach | i secHayue paty(t) wro(ic)) Macrame: i seenti/If you changed your citizenship(s) specify citizenship(s) you held previously and dates of the change Cl canpafees naunapr O eases regres . HyMap nawnapra/Passport number ¥ eo 0 Grancamen crea Ocpanpe 516923892 Dawsps'e PRmmeine MO ARApOTY! |S ar ey ee |) j2{s[o}el2fojije}™ [year oor _day _J[_montn_]|_year_] Oawoher _ eyniuajstreet Little St James oc HyMap KBaTOpbl/apartment number NIA oo jeevacation@gmail.com a ° : —1_ o1 Southern Trust Company nacana/position Chairman o2 so6nacup (pati)/region Virgin Islands a syniua/street Red Hook Quarters Mowe aiairy: HyMap a one Gweer of entries 0 asenamet crac eo6nacun(paéx)/region Minsk © ec ee emeaybting ranter NIA MyMap KBATSpby/' number racupiya/hotet NIA 23. Nanpadasnae thymassHne HoTw Bisiry/Detalled explanation of a purpose of visit TEND DATO Visiting close friends Cerna chaps Tnagai na agpapoye + PTO EFTA00311420

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r Guin Bei panen y PacnyGnlua Genapycy/Have you ever been to the Republic of Belarus (Craw/yes = x) He/no Kani Tex, BLEHAULE TapMiM, Mecya | MaTY anowHera BiaiTy/if yes, please specify dates, places and purpose of your previous visit a/trom NIA nara NIA ae/where NIA wera sisiry/purpose of visit N/A } 25. Nanap soins ¥ Paar Benapych Ha Npeusry Garyuara roma | aryAbHb) TSPMIH “acoBara 3HaxogxeHHa/Previous stays in the Republic of Belarus within a current year and the aggregate term of temporary stay 1) a/from NIA navunts) NIA 4) a/from WA najunta NIA arynbHbs T3pMik Wacosara SHaxospKaHHA/ 2) 3/from NIA rajuntil WA 5) 3/from NIA najuntt NIA ] = on ee “ 3) 3/from NiA nafuntit N/A, 6) a/trom N/A najunta NIA - 76 pise aG0 83a Guia aHynasana/Have your Belarusian visa request been ever refused or your visa was cancelled “ Bire/no rani BaaHaY aany/it yes, specty the date N/A 77. p Bes nag4ac p 3HAXOR RANMA HA TSpUTOph PachyOniki BenapyGs nan ARKaIHaGIs 3a NApyuBNNe Genapyoara saxsHanaycTea/ Have you ever been charged with violating the Belarusian law while in Selarus a Bne/no ani Tax, eucHauue KanV/if yes, specify when N/A . | gpe/and where N/A Cranoyu ayas Ha nbrraHHe He eagge fa aGaaagKosall agMosM f Shue! Babi, AAHAK y ITRIM BhINANKy NaKaeHa Bawa acasicras NpeicyTHadh 3 MaTaH NpaBAAZEHHe iHTSspe'10 3 KOHCYNbCKIM paboTHixam/Positive answer will not necessarily affect negatively the consideration of a visa request, but in this case your p ce Is req d for an interview with a consular officer 28. Uj Seu Ber senapTasatia 3 AKOM-HedyA3t Kpailei/Have you ever Deen Geported from any country a e Byre/no caniif yes, specity when N/A fand from which country NWA 130, Mapwipyt pyxy/itinerery Austrian 90, Austrian 687 (Newark-Vienna-Minsk) } 1. apyos/ sane 89. TpaHcnapTHb! Cposax, sid mpanyrneaxal Means of transport available for your entrance tp the Cpanxl na icsasanna magiec SHaxOQKANHA 6 Means available for stay in the Republic of Belarus Bi] Hanyumn cpogxi/cash D6anxajoca soxi/bank cheques Dssapomis Giner/retum ticket Bz. 6 Rarasopy MeabIBMO@ra CTpaxcnanta/ Medical insurance paxapan apravizalbi (Ha38a, anpAC, Tanetbou)/insurance company (name, ladd phone) Allianz, 9950 Mavland Drive, Richmond. VA 22) a) canpayn 3valid from June 4, 2015 __najuntil June 4, 2016 3. Camel fuma/ Marital DI ssaxcgmyce 7 uimoGe/married Bhne sraxop wun0Ge/single Di passensenei(a)/divorced Dyaaneu (yaawa)widow(er) 503 HK) Spouse” 35. Nposslura mya ‘xOMi) Npi HapamxcHei/Spouse’s last name by birth 57. Tpamanamnctea(h) Myaa (mornd)/Spouse's citizenshay(s) ~ kpainia/country NIA ropanjcty N/A . RoGnacys (paés)/region N/A ~ pce Baw nawnapr, 3anoy raoniuy/if you are accompanied by children and they are included in your Ima/First Name 7 Alara | meaua Hapaypseia/Date and place of birth — NIA NIA N/A NIA N/A N/A Dexnapauen/ Declaration A sanyo, wro inapmaybin, aKaA sMeuuaHa ¥ Tal anKeye, 3’aynneuua paknaquai i npayasisal. A sega, wro napegamnenHe HenpayasiBux 3eecTak ans6o anmaynenve an npacraynenna HeaGxonHEX maKyMeNTay Moma CHYMbIb NaAACTABa ANA AQMOBL 62 yesn3 ¥ Pacny6niky Benapyc. A Taxcama nanapsyKaHel, wTo, Kani rsraa iMcapwaubin Gyaze npbisHaHa HeAaKianNal, Bisa MOKA GbILIb laMynanana ¥ mo6bi MOMaHT. A aGasazyioca na npeiGuuul Y PacnySnixy Benapych Ba Ycranoynenwim napanKy acopmius paricrpausio | naKivylb KE TSPbITOpeiio Aa SAKAHNSHHA TSpMiHy ASCAHHA Bibl. A NanapspKahb! a6 HeaGxopHacui MeYyb NaQvac NaesqxKi MeAMLLIHCKYIO paxoyky, AKaa annasAgae SaxaHanaycrey Pacny6niki Benapych / 1 dectare that information in this application is true and correct. I am aware that any false statements or refusal to submit the necessary doc ents may lead to withholding a permit to enter Belarus. | am also wamed 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 will register according to the established procedure and leave the to ‘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 legislatio 3 5 e {SRE cat aagnic/Signat fofejofs}2fofs}s' |_day _|_month ed EFTA00311421