20002-1103603213119/2015 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 that any false statements will lead to the annulment of a visa already granted and may also render me liable to prosecution under Russian law. of Russia upon the expiry of the visa If granted. I understand that possession of a visa does not automatically. I will not seek compensation if I am refused to enter Russia. to my application being rejected or I undertake to leave the territory entitle its bearer to enter Russia " - not to be filled by holders of diplomatic and official passports 1. Nagonalitowu homely had USSR or RUWall clizenstip. please indcate %hen and why you leo t) UNITED STATES 6. Purpose of visit BUSINESS 7. Category and type of visa COMMON BUSINESS 2. Last name(as in passport) EPSTEIN 8. Number of entries Single entry Double entry Multiple entry X 3. First and middle names (as in passport) JEFFREY EDWARD 9. Date of entry In Russia 24/04/2015 okyrrnyy) 10. Date of departure from Russia 30/04/2015 (thririaryy) 4. Date of (rklarrayy) birth 5. Sex i'll X F 11. Passport No Issued by Date of Issue (ddannnyy) 30/06/2014 OF STATE Valid until (dowiwy) 29/06/2016 US DEPARTMENT 12. Type of passport diplomatic official tourist X other please specify 13. Russian Institution or organization to be visited? (bburial - on end rode ance rumbar of the host Wild =levy. fsr bushessmsn - name of the host alginates and men. {or male pawns-Ian name. IN nano. coddle names and bane address of me I og) FUND ST PETERSBURG INTERNATIONAL ECONOMIC FORUM, SREDNIY PROSPECT 88, BUILDING A, ST PETERSBURG, RUSSIA, 199106 14. Itinerary(piaces 'grist) 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 trip to and stay In Russia? Indepe