ON-LINE VISA APPLICATION FORM Visa …

1 ON-LINE visa APPLICATION FORMP hotograph and information (automatically generated).Place forphotographDate (dd/mm/yyyy), personal signatureApplication form recipient:Basis (voucher, dir. No, inv. No):The estimated date of visit to the RC: APPLICATION No (web-site):The date of processing: 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 inelectronic form for the purposes of making a decision on visa issuance. Ideclare that data provided in the APPLICATION form are full and correct. Iam aware that any false information may be a cause for the denial of visaor for the cancellation of the previously issued visa and may lead to otherconsequences provided for by the legislation of the Russian to the receipt of visa , I pledge to leave the territory of theRussian Federation before the visa expiration date.

2 I am aware that validvisa does not automatically allow to enter the territory of the RussianFederation. In case of denial of entry, I will not seek any compensationfor potential \ 20:01:46 visa APPLICATION Center ILS (NewYork) visa APPLICATION Center ILS (NewYork)012925264245713/10/20181. Nationality (if you formerly hadUSSR or Russian citizenship, pleaseindicate when and why you lost it).UNITED STATES, 23/10/1988, EMIGRATED TO THE USA2. Surname (as in passport).STEINBERG3. First name, other names, patronimic(as in passport).NATALIA4. Date of birth (dd/mm/yyyy).17/01/19625. of passport:ORDINARYP assport No:488165159 Issued by:US DEPT. OF STATEDate of issue:19/11/2012 Valid until:18/11/20227.

3 Purpose of Category and type of TOURIST9. Number of Date of arrival and - 14/04/202111. Host organisation you intend name:OOO "MULTI visa SERVICE"Reference No:012925 Confirmation No:21621508 Address:123181, MOSCOW, UL. ISAKOVSKOGO 24-5112. Route of journey (destinationpoints).SAINT-PETERSBURGPage 1 of 42000202642457113. Your permanent address, telephonenumber, fax number, BARCLAY ST., APT. 52G, NEW YORK, NY 10007, TEL: 9175668272, Current/latest place of , COACH, 10 BARCLAY ST., NEW YORK, NY 10007, TEL: 2122330219,EMAIL: Information about previous you ever been issued a Russianvisa?YESWhen and where?1) 28/04/2017 NEW YORK2) 28/06/2016 BERLIN, GERMANY3) 21/02/2013 BERLIN, GERMANY4) 22/06/2011 WASHINGTON16.

4 Who will pay for your trip to andstay in Russia?INDEPENDENTLY17. Information about health you have health insurance that isvalid in Russia?YESName of the insurance company,insurance number:BLUE CROSS BLUE SHIELD18. Other names used in the past(maiden, pen-name, religious, etc.).1) GALUSHKA NATALIA ALEXANDROVNA19. Your place of birth (if you wereborn in Russia, please specify when andwhich country you emigrated to).RUSSIA23/10/1988, UNITED STATES20. Additional information about status:DIVORCEDS pouse s full name (if divorced orseparated, please specify maiden nameif applicable):PETER STEINBERGS pouse s date of birth:08/08/1952 Spouse s place of birth:HANAU, GERMANYYour father s full name:GALUSHKA ALEKSANDRYour mother s full name:GALUSHKA TATIANADo you currently have relatives inRussia?

5 NO21. Additional visa may be refused to persons who are within specific categories defined by the law as inadmissible to answer yes does not automatically signify ineligibility for a visa . In this case you may be required topersonally appear before a consular Have you ever been arrested orconvicted for any offence? Have you ever been afflicted witha communicable disease of public healthsignificance or a dangerous physicalphysical or mental disorder? Have youever been a drug abuser or an addict? Have you ever been refused aRussian visa ? Has your Russian visa ever beencanceled? Have you ever been deported fromRussia?NOPage 2 of Have you ever tried to obtain orassisted others to obtain a Russianvisa or enter Russia by providingmisleading or false information?

6 Have you ever overstayed yourRussian visa or stayed unlawfully inRussia?NO22. Planned place of stay in , birth date, address and phonenumber of person or hotel in Russiathat you plan to stay with:PRIBALTIYSKAYA HOTEL, 14 KORABLESTROITELEY STREET, ST. PETERSBURG 199226,TEL: 812-329-262623. Information about completing this APPLICATION been completedpersonally by you?YES24. Additional passport your passport ever been lost orstolen?NOList all countries which have everissued you a passport:UNITED STATES25. Information about your previoustrips ) ITALY, 19/01/20182) GERMANY, 01/11/20173) UNITED KINGDOM, 27/10/20174) UNITED KINGDOM, 30/08/20175) CHINA, 23/06/20176) GERMANY, 18/02/20177) AUSTRIA, 05/11/20178) UNITED KINGDOM, 14/09/20179) AUSTRIA, 22/04/201610) FRANCE, 01/03/201611) ITALY, 31/01/201612) UNITED KINGDOM, 18/01/201613) CYPRUS, 13/10/201514) NORWAY, 02/07/201515) UNITED KINGDOM, 30/05/201516) SWITZERLAND, 21/04/201517) PORTUGAL, 08/02/201518) UNITED KINGDOM, 11/11/201419) FRANCE, 11/08/201420) SWITZERLAND, 12/07/201421) AUSTRIA, 09/12/201322) ESTONIA, 10/08/201323) LATVIA, 04/08/201324) LUXEMBOURG, 06/06/201325) AUSTRIA, 02/04/201226)

7 RUSSIAN FEDERATION, 07/03/201327) RUSSIAN FEDERATION, 26/08/201628) RUSSIAN FEDERATION, 17/06/201729) RUSSIAN FEDERATION, 06/07/201730) RUSSIAN FEDERATION, 27/06/2011 Page 3 of 426. List your last two places of work,excluding the current one. 1)Company name:LSI BERLINA ddress:PFALZBURGER STR., BERLIN, GERMANYYour position:LANGIAGE INSTRUCTORT elephone number:0308553681 Your chief s surname:DR. HOFFMANND ates of joining and dismissal:06/1999 - 05/2005 2)Company name:INTERLOTA ddress:156 OCEAN PKWY, NEW YORK, NYYour position:LANGUAGE INSTRUCTORT elephone number:917366-5634 Your chief s surname:MS. KORENBLITD ates of joining and dismissal:03/1996 - 04/199927.

8 List all educational institutionsyou ever attended, except high schools. 1)Name:GEORGE WASHINGTON UNIVERSITYC ourse of study:INTERNATIONAL BUSINESSA ddress and telephone number:1129 NEW HAMPSHIRE AVE. NW, WASHINGTON, DC. 2029942492 Dates of admission and graduation:09/1993 - 05/1995 2)Name:LENINGRAD STATE UNIVERSITYC ourse of study:ORIENTAL STUDIESA ddress and telephone number:UNIVERSITY EMB., 7/9, LENINGRADD ates of admission and graduation:09/1979 - 06/198428. Special training and you have any specialized skills,training or experience related to fire-arms and explosives or to nuclearmatters, biological or chemicalsubstance?NO29. List all professional, civil andcharity organizations which youare/were a member of orcooperate/cooperated ) INTERNATIONAL COACH ACADEMY30.

9 Military you ever performed a militaryservice?NONE31. Armed you ever been involved in armedconflicts, either as a member of themilitary service or a victim?NONEPage 4 of 4