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 declare that data provided in the APPLICATION form are full andcorrect. I am aware that any false information may be a cause for thedenial of visa or for the cancellation of the previously issued visa andmay lead to other consequences provided for by the legislation of theRussian Federation. Subject to the receipt of visa , I pledge to leavethe territory of the Russian Federation before the visa expiration am aware that valid visa does not automatically allow to enter theterritory of the Russian Federation.

2 In case of denial of entry, I willnot seek any compensation for potential \ 20:29:33 visa APPLICATION Center VHS (Paris) visa APPLICATION Center VHS(Paris)0135071588078624/03/20161. Nationality (if you formerly hadUSSR or Russian citizenship, pleaseindicate when and why you lost it).FRANCE2. Surname (as in passport).DURAND3. First name, other names, patronimic(as in passport).NATHALIE LAURENCE LOUISE4. Date of birth (dd/mm/yyyy).15/09/19805. No:12FR45612 Date of issue:12/10/2010 Valid until:11/10/20207. Purpose of Category and type of TOURIST9. Number of Date of arrival and - 16/08/201611. Host organisation you intend name: visa SUPPORT CENTER LTDR eference No:013507 Confirmation No:013507 Address:1-ST KOZHEVNICHESKIY PEREULOK 6/1 115114 MOSCOW12. Route of journey (destinationpoints).SAINT-PETERSBURGPage 1 of 22000201588078613. Children under 16 years and otherrelatives written in your you travel with children under 16years or other relatives written inyour passport?

3 NO14. Your permanent address, telephonenumber, fax number, BD DE LYON 31000 TOULOUSE, TEL: 0662232323, Place of work or study (position,company name, address, telephonenumber, fax number, E-mail).TOPCOM, SALE MANAGER, 125 RUE DE ROME 31000 TOULOUSE, TEL: 056223232,EMAIL: Information about your previoustrips to many times have you been to Russia?-17. Information about health you have health insurance that isvalid in Russia?YESName of the insurance company,insurance number:MAPFRE ASISTENCIA N W200130495218. Other names used in the past(maiden, pen-name, religious, etc.).1) LABORDE (SI DURAND EP. LABORDE)19. Your place of birth (if you wereborn in Russia, please specify when andwhich country you emigrated to).TOULOUSE20. Additional information about you currently have relatives inRussia?NOPage 2 of 2