EFTA00311420.pdf

APYItafaliblall ntraanit 1O tiE Flu ED IN BIOCX irnYitj P3CHYSJUKA BFJ1APYCb THE REPUBLIC OF BELARUS BI3ABAR AHKETA VISA APPLICATION FORM 1. nposalwteyFamily name 4. non/Sia Epstein Coramamar./Pheto 2. Ins/First name Jeffrey • Islam 'seat nroaluers,yncir Nay Aisisome/Other names and (or) maiden name Cleauo-a/female NIA 5. An napaAwaisii/Date of birth 6. !Seca napamotemfalace of birth Cirresfamma assamd/ 2day 0 10 I 1 1 9 1 5 1 3 Wranazemrnby USA rapaAyNew York For oftidal use 1 year acfmaas (pa₹aryregion New York Am storm: 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. tire° naturiapra/Passport number 12. Sara ateituw/Date et Sr 516923892 310 016 2 10 114 rinarnilnedordiray 10. Ka eatsweradIssuing authority day _ neat 1 year Elaintiamainsei/apiasetic US Dtparboont of Saes Panama WY Clcnyx6oetaroffnal 13. Tapia 10ernmaNaid end pans PAKWaerflother document 11. µse Dew/Mace of !me 219 0 1 6 2 1 0 1 1 1 6 " USA ocrole day month yleaf 0 motile 14. Mac cranara neap Notepaaafremianed home address Kaaba/country USVI goonaatb(paetyWyegjan St. Thomas rbbeway Little St. James aynivaistreer Little St James Hying cninebulidng number NIA Hyman kaaraiapaitment number N/A ••ymap aneacro/phone number ern.' irrevacatonggmaitcom ts. 14ecia npay s i writes., aApaciPiace of work and wart address eeebeeserceerwmpri Southern Trust Company nouutonxsibon Chairman Epamajcourdyy USA ao6naau. (yakenyrogion Virgin Islands romichy St Thomas ay/ilia/sheet Red Hook Quarters Ityle Mew: 0 Ty•Ktr 'asap nornibutang number Suite 8-3 "WV taftednia/phone number 16. Kanropsa nos/Category of Visa 17. Ten eisiertype of vea 18. Komeacts yenal/Number of entries Ansai Cymru CI yam y coy.o;•••of Clambarbanaaeindividuai umaminiasitranse meacesceasisingle tYmaY11.60 Ile ATae. ClranalsasigouP ElKaponcangtomagshogt-terrn Asyspasoemidouble D ream Jatojranoisionan/long•term usiamnons/Multple nwrekmar 19. Tapia Assimat kw/Tenn or visa validity ourama mmHg Ha Tapia anamaramm/ O Me Maio PA wiry from na until fora term of stay O rasa 1 1 day 0 1 91 2 1 0 1 1 1 5 day 0 8 1 2 2 0 1 15 Ills 0 sa ,S month year month 1 year days row 20. Hama aanpaiusaal apraniniaal ado ha 3anparuaKailif Keay/Name or liming organisation or poson woe occe? mrsee Karyna Shullak or awe ..nano. 21. Pupae 3anpawaimenw apraressail ado aco644/04dress of man crganbabon or person 0 cow no6nooni (poem n s ion i/1 1sIt zonneyanyee. - rcomirihr Delwin synlaistnet HMV Novaibuilding number NIA innan manaliaParbnent number Wing nne4ona/phone nutter la piymap marbeiree number N/A emaa 22. Acpac siagoasamis 6enagro/Address of stySans Osipafroaa: sofmaala(Paeff l0n Minsk roparycly Reheat Knee aorawding number NM N 'mop marups/warbnert number rarusliaa/tiotei N/A 23. nailpeenime MyraaltHre pornaisiry,Metaled aplanabon of a Paden a rwa 1Intiaglia••• Visiting close friends Cale..sys Oiler Tnertai na auteapoue 1. PTO 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 pupatedItur Plea" visit 3/horn N/A flan' N/A zuelwhere N/A 'era stury/curpose of visit WA 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 naluoth N/A na/untl N/A aryssns opiate 4acoaara swairogramo/ 1) 3/from N/A 4) a/han WA the rir term of temporary stay 2)3/from NIA na/untl WA 5) a/froin N/A nai untg NIA 3) 3/horn nwunoi N/A 6) a/from NIA remid N/A 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 N/A rani rev, abonavue awn, Yes, speofy tit e daze 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 antioevrfavaa vis abet aquas y nom abinailitY ilawaAalia Baum aca0lcrall nobcvniacito 3 Hared case npaaweims armpit* a rowcynbcom panesinaM/POSalve answer mw1 not necessarily affect negatively the consideration alai/Ka requests bailie* 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 ElHe/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/ 32. 3eecnd a6 Aar-amps mecuruemocara crpaxacomes/Medical insurance Means available for stay in the Republic Of Marts information crpoosaa apraHhauriaa (Hama, awe, nne6cii)/Insurarce compacw (name, O nanc,116111 CAOAH/CaSh 136aitacioill taxi/bank cheques address, phone) Allianz. 9950 'Wayland Drive. Richmond. VA alaAbMatai icanteaeclit cards rloaapanni timer/return ticket 23233 ❑gapownta told/travel cheques Elnpaxonvoine/accomirodetion renpa9mis 3/veld from June 4, 2015 cta/unbi June 4, 2016 33. C.aiieRitae cratioeluna/Markal Saws ❑ 3.4aXOCKYOU 9 uwedelmamed 8ne 3Hilactlerils-a 9 runi06e/Single ElpaseealitnagaythyOrCed Elymnai (mana)/widow(er) ooe's past name by 34. Opoasiurva moo ounwecijrapouseg family name 35. IIP03akfma Kim (voird) nribl naPacCiolimi/Sp N/A N/A Tr/ pamanmicrea(m) myna Ses btirenskp(s) 36. Ina i MUSH blew ,qne (xctisd)/Spause s first ant other names N/A NIA 38. Ara rialsaroareita nywa Nowa 39. Meota eaCiaftrotois iwaobitoirri)Spouses place of birth 500uSeS date of birth Kpaimak ouppy NIA ropaway N/A ecenacub (pees)/region WA day month year 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 leo/First Name Aare I media napamicivini/Date and place of birth NIA N/A N/A N/A N/A N/A N/A 41. /13tutapatioes/ Declaration WIO nalleAatitneHHe saittnroo, urro inchappsauteri, ems 3neuntalla 9 mai apace*, aracinveuua havnaintail I npa9n3loaii. R seam, s; Mn aM4Babl Ba menpa9A3labla seecraic ano6o ameatnewne as npaqcraineint wea6a011s60 narienevrati NOB91 ClhOBtAlb isRACTuarl Fscny6nitry Benapyco. Si nycape rungs/beam , urro, Kant rsran hapapmataui 6ya3e not/mama item vnaamaii, siaa non 6bIllb 9914312 Y 9 arhopmitts poricrpattbno i airynciaaHa 9 ino6bi mositarr. Aa6aosnydcs no npu6talµl P3cflY6nlicy 6enapycli ea tcranotnemini napaoicy 3.3mioemint rapidity fl3eRiela sta. R namip3mtans a6 uea6xotoauti nes naavac naesaxi meauttomayio nainityue ve niporroptin0 na crptuco9ity, man annaannae 3avamen490 8Y P3criVemild sensinth refusal to submit the necessary I declare that information in this application is true and correct. I am aware that any false statements or found to be Incorrect, the visa documents may lead to withholding a pennk to enter Belarus. I am also warned that If this information is Belams I will register according to the established procedure and leave the may be cancelled at any time. On arrival to the Republic of have a medical insurance that terribly d the Republic of Betsrus before my visa expires. I am awn that during my travel I need to corresponds to the requirements of BelaruSian legetlatbn. 43. Para naanIcatum/Date el signature 42. Aca6icrw natinkThigeatise 0 8 0 9 2 0 1 5 day month cur EFTA00311421