2 APYItafaliblall ntraanit P3CHYSJUKA BFJ1APYCb BI3ABAR AHKETA 1O tiE Flu ED IN BIOCX irnYitj THE REPUBLIC OF BELARUS VISA APPLICATION FORM 1. nposalwteyFamily name Epstein 2. Ins/First name Jeffrey • Islam 'seat nroaluers,yncir Nay Aisisome/Other names and (or) maiden name NIA 4. non/Sia Cleauo-a/female Coramamar./Pheto 5. An napaAwaisii/Date of birth day 10 I 1 year1 1 9 1 5 1 3 7. tbmeinuneleile) Manama ma(s)gurrere Miens/M(5) American . . • • Kan' Bbl wan; rOalnelralclea(s), Mashie Mainaviiicnsa(s), mega) 6amc(I) Bac pasell, I eantisee aalY0e) nr0(o4) isenarlf you changed mur ritizenship(s) speoN atirenship(s) you Mid previously and Skate dates of the change N/A S. Tan natunapra/fype al passport 6. !Seca napamotemfalace of birth Wranazemrnby USA rapaAyNew York acfmaas (pa₹aryregion New York rinarnilnedordiray Elaintiamainsei/apiasetic Clcnyx6oetaroffnal pans PAKWaerflother document 6. tire° naturiapra/Passport number 516923892 10. Ka eatsweradIssuing authority US Dtparboont of Saes 12. Sara ateituw/Date et Sr 310 016 2 1 0 114 day _ neat 1 year 13. Tapia 10ernmaNaid end 11. µse Dew/Mace of !me USA 14. Mac cranara neap Notepaaafremianed home address Kaaba/country USVI rbbeway Little St. James Hying cninebulidng number NIA ••ymap aneacro/phone number ts. 14ecia npay s i writes., aApaciPiace of work and wart address eeebeesercee rwmpri Southern Trust Company Epamajcourdyy USA romichy St Thomas 'asap nornibutang number Suite 8-3 16. Kanropsa nos/Category of Visa Clambarbanaaeindividuai ClranalsasigouP 219 0 1 6 Cirresfamma assamd/ For oftidal use Am storm: Panama WY 2 1 0 1 1 1 6 " daymonth yleaf 0 motile ocrole goonaatb(paetyWyegjan St. Thomas aynivaistreer Little St James Hyman kaaraiapaitment number N/A ern.' irrevacatonggmaitcom nouutonxsibon Chairman ao6naau. (yakenyrogion Virgin Islands ay/ilia/sheet Red Hook Quarters "WV taftednia/phone number 17. Ten eisiertype of vea 18. Komeacts yenal/Number of entries umaminiasitranse ElKaponcangtomagshogt-terrn Jatojranoisionan/long•term 19. Tapia Assimat kw/Tenn or visa validity from 1 1 0 1 91 2 1 0 1 1 1 5 day month year 20. Hama aanpaiusaal apraniniaal ado ha 3anparuaKailif Keay/Name or liming organisation or poson na until meacesceasisingle Asyspasoemidouble usiamnons/Multple 0 8 1 2 day0 1 1 5 month 1 year 2 Ha Tapia anamaramm/ fora term of stay Ills days Karyna Shullak 21. Pupae 3anpawaimenw apraressail ado aco644/04dress of man crganbabon or person no6nooni (poem ion i ns /11sIt synlaistnet innan manaliaParbnent number piymap marbeiree number N/A 22. Acpac siagoasamis 6enagro/Address of stySans sofmaala(Paeff l0n Minsk 'mop marups/warbnert number 23. nailpeenime MyraaltHre pornaisiry,Metaled aplanabon of a Paden a Visiting close friends - rcomirihr Delwin HMV Novaibuilding number NIA Wing nne4ona/phone nutter emaa roparycly Reheat Knee aorawding number NM rarusliaa/tiotei N/A Ityle Mew: 0 Ty•Ktr Ansai Cymru CI yam y coy.o;•••of tYmaY11.60 Ile ATae. D ream nwrekmar ourama mmHg O Me Maio PA wiry O rasa 0 sa ,S row woe occe? mrsee or awe ..nano. 0 cow zonneyanyee. la Osipafroaa: N rwa 1Intiaglia••• Cale..sys Oiler Tnertai na auteapoue 1. PTO 0 EFTA00311420 24. UJ data Obi panel; y Osawituiletbi benepyci.hiave you ever been to the ReptiMic of Bolan Drar/Yes Oi ne/no semi sas, ebowaieue opera% Santa I POTY WM/an &IBM( 9eS Please We* data, places and pupated Itur Plea" visit 3/horn N/A flan' N/A 'eraWA stury/curpose of visit zuelwhere N/A 25. Fianna/vs a arns, 9 Pacm6niry benaoyci, Ha npauary Gary iara nacia i &yawns open vacoeara 3+4E(OLPG)HHR/BresOuS Says in the Republic of Beams within a current year and the aggregate term of temporary stay 1) 3/from N/A 2)3/from NIA 3) 3/horn naluoth N/A na/untl WA nwunoi N/A 4) a/han WA 5) a/froin N/A 6) a/from NIA na/untl N/A naiuntg NIA remid N/A aryssns opiate 4acoaara swairogramo/ the rir term of temporary stay days 26. Le Sumo Bat. ouioynenayeienapyotan arse a(So also tuna awymisatopirave your Boletus:tan SW request been ever refused or your vha was cancelled Orarckes mrwno rani rev, abonavue awn, Yes, speofy tit e daze N/A 27. 1f naawianl Si nannat panentuara nraxornyanmm Ha tHadltabll Pacnyenho Eenapya. NA baaliliKilb 3a napyttesne 6enapyoora sarananaycorai Have you ever been charged with violating the Belarusian law while h eelarus prase/yes Egrre/no onl Tar, ilibesakise rimed yes, specfy when N/A I we/and where . O1110914bi 2401093 Ha ntermitte we ewe Ad a6aernoceal antioevrfavaavis abet aquas y nom abinailitY ilawaAalia Baum aca0lcrall nobcvniacito 3 Hared npaaweims armpit* a rowcynbcom panesinaM/POSalve answer mw1 not necessarily affect negatively the consideration alai/Ka requests bailie* case your presence is requested fa an Interview with a consular otiker 28. Ili faini mnapTasatts 3 stsoimierawob canal/Have you ever been denoted from are county Onknes El He/n° rani Tax, oesnantie icanyir ws, specify Mien WA 13 trot ipalioand from which coutry WA 29. Toast:nal:nisei cpotox, Rd npaarneawanta ono teeny 9 paarosfory senapyc, 30. Mapwpyr pyxyptinerary Means of tramped available fa your entrance to the Republic of Belarus Austrian 90. Austrian 607 (Noworbillegmaalhok) Commercial Airlines 31. Co04.4 M icsaeame ticeraC 3PlaX0Asains y Psmyenktbi 6enapycs/ Means available for stay in the Republic Of Marts O nanc,116111 CAOAH/CaSh alaAbMatai icanteaeclit cards ❑gapownta told/travel cheques 136aitacioill taxi/bank cheques rloaapanni timer/return ticket Elnpaxonvoine/accomirodetion 33. C.aiieRitae cratioeluna/Markal Saws ❑ 3.4aXOCKYOU 9 uwedelmamed 8ne 3Hilactlerils-a 9 runi06e/Single ElpaseealitnagaythyOrCed Elymnai (mana)/widow(er) 32. 3eecnd a6 Aar-amps mecuruemocara crpaxacomes/Medical insurance information crpoosaa apraHhauriaa (Hama, awe, nne6cii)/Insurarce compacw (name, address, phone) Allianz. 9950 'Wayland Drive. Richmond. VA 23233 renpa9mis 3/veld from June 4, 2015 cta/unbi June 4, 2016 34. Opoasiurva moo ounwecijrapouseg family name 35. IIP03akfma Kim (voird) nribl naPacCiolimi/Spooe's past name by N/A N/A 36. Ina i MUSH blew ,qne (xctisd)/Spause s first ant other names Tr/ pamanmicrea(m) myna Ses btirenskp(s) N/A 38. Ara rialsaroareita nywa Nowa 500uSeS date of birth daymonth yearNIA 39. Meota eaCiaftrotois iwaobitoirri)Spouses place of birth Kpaimakouppy NIA ecenacub (pees)/region WA ropaway N/A 40. Kasl (lac dmpaaamovole nefi I ow nieces' y Data nawnapr, sancnwite ra6nitry/If you are aoSaWy ildren air they we included in your passport Ali In the table below nposskuva/Famlly name NIA leo/First Name Aare I media napamicivini/Date and place of birth N/A N/A N/A N/A N/A N/A 41. /13tutapatioes/ Declaration saittnroo, urro inchappsauteri, ems 3neuntalla 9 mai apace*, aracinveuua havnaintail I npa9n3loaii. R seam, WIO nalleAatitneHHe menpa9A3labla seecraic ano6o ameatnewne as npaqcraineints; wea6a011s6 0 narienevra ti NOB91 ClhOBtAlb isRACTuarl Mn aM4Babl Ba 9914312 Y Fscny6nitry Benapyco. Si nycape rungs/beam, urro, Kant rsran hapapmataui 6ya3e not/mama item vnaamaii, siaa non 6bIllb airynciaaHa 9 ino6bi mositarr. Aa6aosnydcs no npu6talµl 9P3cflY6nlicy 6enapycli ea tcranotnemini napaoicy arhopmitts poricrpattbno i nainityue ve niporroptin0 na 3.3mioemint rapidity fl3eRiela sta. R namip3mtans a6 uea6xotoauti nes naavac naesaxi meauttomayio crptuco9ity, man annaannae 3avamen49 08Y P3criVemild sensinth I declare that information in this application is true and correct. I am aware that any false statements or refusal to submit the necessary documents may lead to withholding a pennk to enter Belarus. I am also warned that If this information is found to be Incorrect, the visa may be cancelled at any time. On arrival to the Republic of Belams I will register according to the established procedure and leave the terribly d the Republic of Betsrus before my visa expires. I am awn that during my travel I need to have a medical insurance that corresponds to the requirements of BelaruSian legetlatbn. 42. Aca6icrw natinkThigeatise 43. Para naanIcatum/Date el signature 0 8 0 9 2 0 1 5 day month cur EFTA00311421