VISA APPLICATION IMPORTANT! Please type or print using ballpoint 71 declare that date supplant-Foy me is correct rt ompletc. I am aware that any false statements will lead to my application being releC or to the annulment of a visa already granted and may also render me liable to prosecution under Russian law. I undertake to leave the territory of the Russian Federation upon the expiry of the visa, if granted. I understand that possession of a visa does not entitle its bearer to enter Russia. I will not seek compensation if I am refused to enter Russia . not to be filled 6y holders of diplomatic and official pass • oft 1. Nationality(s you lorsibbid USSR re Rissonoliterario Praia eataW aadtytoo nn e) USA 2. Last names arum) EPSTEIN p Cfst and middle names (at sr amr JEFFREY EDWARD 4. Dina of birth 20/01/53 0.0) .11•Pant*fifti 469911707 Iftlnittb 7. e of visa BUg ory InIstYs" S. Number of *stria Snots tatty n Dottie entryD Multiple entlylEl Leyte of entry M Russia 10. Date of departure from Russia 18 01 11 Dote of Issue (estrany) Issued by US DEPARTMENT OF STATE Valid until (5oaem) omits 27/05/10 26/05/20 18 01 12 (atm 12. Type of passport dpiornabc n official Er — tourist dear ri please specify 13. Russian institution or organization to bo visited? On urns-Tweed whom ranted Os Wane coppery.* Owns-en - P-te Ci tie ?Mg teganantead tooth re — . more - Liu sane. Can needeatenes and knit Ohtani bebop) I MOO 131,1M1101, MOCKBA 14. Itinerary(Mceicrist) MOSCOW n1fi. Do you have a medical Insurance valid in Russia? yes E nem Weal? UNITED HEALTHCARE 10. Who will pay for your trip to and stay In Russia? SELF 17. fibrital status married O simple (never married) [:l aborted Enseparated n widowed O. ie. Sousa fun name (nerarotoir sersaled euseistassailassamespet era) I,9. Spouse's date of birth birth 20.Spouays place of SEYMOUR EPSTEIN ,PAYarrg5stu-Pgill ...„„,„ ^21. Your lather's full awns 23. Have you ever