20002-110360321311912015 9:30:31 PM Completed: visa.kdmid.ru Destination: Visa Application Center ILS (New York); VISA APPLICATION I declare that all data given in this form is complete and true. I am aware to the annulment of a visa already granted and may also render me liable of Russia upon the expiry of the visa If granted. I understand that automatically. I will not seek compensation if I am refused to enter Russia. that any false statements will lead to my application being rejected or to prosecution under Russian law. I undertake to leave the territory possession of a visa does not entitle its bearer to enter Russia " - not to be filled by holders of diplomatic and official passports 1. NatIonality0i you homely had USSR or Rusean cazenshp, please indcle when and why you bat 0 UNITED STATES 6. Purpose of visit BUSINESS 7. Category and type of visa COMMON BUSINESS 2. Last name(as in passFor) EPSTEIN 8. Number of entries Single entry Double en ry Multiple entry X 3. First and middle names (as in passport) JEFFREY EDWARD 9. Date of entry in Russia 24/04/2015 ov,,,,wy) 10. Date of departure from Russia 30/04/2015 (ddrinnilyy) 4. Date of birth 20/01/1953 (ddlnmlyy) 5. Sex M X it Passport No 516923892 Date of issue sisistom 30/06/2014 Issued by US DEPARTMENT OF STATE Valid until (ssymbyy) 29/06/2016 12. Type of passport diplomatic official tourist X other please specify 13. Russian Institution or organization to be visited? (for tourists -nuns and reference rumter ol the host tourist company. for businessmen - name ol the host organization and ken. lor pdvale pantos - lasl name. tisl name. coddle names and hone address al die host) FUND ST PETERSBURG INTERNATIONAL ECONOMIC FORUM, SREDNIY PROSPECT 88, BUILDING A, ST PETERSBURG, RUSSIA, 199106 14. Itinerary(places of dui) SAINT-PETERSBURG "15. Do you have a medical insurance valid in Russia? yes x Please specify? UNITED HEALTHCARE no 16. Who will pay for your tr