ON-LINE VISA APPLICATION FORM 20002 \ 24.05.2018 22:03:53 Consulate General of Russia in New York 1. Nationality (if you formerly had UNITED STATES USSR or Russian citizenship, please indicate when and why you lost it). 2. Surname (as in passport). EPSTEIN 3. First name, other names, patronimic JEFFREY EDWARD (as in passport). 4. Oate of bir;th (dcymm/yyy . 20/01/1953 5. Sex. MALE 6. Passport. Type of passport: ORDINARY Passport NO: Issued by: UNITED STATES DEPARTMENT OF STATE Date of issue: 23/05/2016 valid until: 22/05/2026 7. Purpose of visit. BUSINESS 8. category and type of visa. COMMON BUSINESS 9. Number of entries. MULTI 10. bate of arrival and departure. 24/07/2018 - 28/07/2018 11. Host organisation you intend to visit. Company name: ASSOCIATION OF NONGOVERNMENTAL PENSION FUNDS TIN: NONE Invitation No: NONE Directive NO: NONE Address: 2 ISVETNOI BOULEVARD, MOSCOW, RUSSIA 127051 12. Route of journey (destination MOSCOW, SAINT-PETERSBURG points). Photograph and signature. Place for photograph Date (dd/mm/yyyy), personal signature Service information (automatically generated). Application form recipient: Consulate General of Russia in New York Basis (voucher, dir. No, inv. No): NONE The estimated date of visit to the RC: Application No (web-site): The date of processing: 5/24/2018 Application NO (VAC): The date of processing by the VAC: Request NO in Russian Consulate (RC): I hereby agree to the processing and transfer of my personal data in electronic form for the purposes of making a decision on visa issuance. I declare that data provided in the application form are full and correct. am aware that any false information may be a cause for the denial of visa or for the cancellation of the previously issued visa and may lead to other consequences provided for by the legislation of the Russian Federation. Subject to the receipt of visa, I pledge to leave the territory of the Russian Federatio