VISA APPLICATION IMPORTANT! Please type or print using ballpoint 'I declare !hut dale suppled is correct an complete. I am aware that any false statements wilt 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 by holders of diplomatic and official pan • orb 1. Nationety(ryor int RS USSR or Assuan omen* SW redraw WS ad sty pi MI A) USA 2. Last nimbusin arum) EPSTEIN inirst and middle names (a Br pmr0 JEFFREY EDWARD sEratemt a Ca tegoryI ars type of visa a Number of entries Sngls entry 0 Mutes *MC] Mufti. entry S. Dote of entry hi Russia 10. Date of departure from Russia 4. Data of birth 20/01/53 18 01 11 11. Passport No 469911707 Dote of Issue Warown) issued by US DEPARTMENT OF STATE Valid until (earn 12. Type of passport dpiernabc other 0 please specify 13. Russian Institution or organization to be visited? Orr wive - Mee lel Nene* reetercres Mallailitcoroasylor basoessren - Lk". a ee ?WU ',gammonad Lamar pre organ-tai name rya made eines ate nos Cass or he Mu) MOO BI,M1101, MOCKBA 14.ftineraryouotsano swim 27/05/10 26/05/20 18 01 12 (atom offIclarrn tourist MOSCOW n 16. Do you have a medical insurers.* valid in Russia? Yes Please WSW? UNITED HEALTHCARE 10. Who will pay for your trip to and stay In Russia? SELF 17. MarItal status mailed O single (never monied) 0 din:ward EFseparsted n „mind 10. Spouse's fun name (resserlerreprons peasenseisadawieseinelicare) 19. Spouse's date of birth (arunvy) no s 20. Spouse's place of birth 7 -212y regs gi —21. Your lather's ha name PAULA EPSTEIN SEYMOUR EPSTEIN . I 23. Hove you ever been issued a Russian