Consulate General of Russian Federation

I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware that any false statements will lead to my application being rejected or to the annulment of a visa already granted and may also render me liable to prosecution under the legislation of the Russian Federation. I undertake to leave the territory of the Russian Federation upon the expiry of the visa, if granted/ I am aware that the fact that a visa has been granted to me does not mean that I will be entitled to enter the territory of the Russian Federation, if any reasons are appear. In a case of refusal of entry I do not have  a right to compensation of damage.

** - Not to be filled by holders of diplomatic and official passports

1. Present citizenship (if you formerly had USSR or Russian citizenship, please indicate when and why you lost it)   USA

2. Last name (as in passport, in capital letters)

PUBLIC

3. First and middle names (as in passport)

 JOHN QUINCY

4. Other names ever used (maiden name, professional, religious aliases)

 WOMEN MAY HAVE MAIDEN NAME

5. Place of birth (if born in Russia, please indicate when and to what country you emigrated)

    ST. LOUIS, MISSOURI   USA

6. Date of birth (DD/MM/YY)

7.  Sex

9. Russian institution or organization to be visited (name and address, phone, fax number, E-mail (if known), name of contact person)

REFER TO FORM FROM CHI FOR # 11, #12, & #13

8. Purpose of visit

**10. Itinerary (places to be visited)

11. Date of entry (DD/MM/YY)

12. Date of departure (DD/MM/YY)

14. Passport number

Passport issued by

Date of issue

Valid until

20. Spouse?s full name (even if divorced or separated, please indicate maiden name if applicable)

21.Spouse?s date of birth (dd/mm/yy)

**23. Your father?s full name

**24. Your mother?s full name

**27. List all countries you have visited in the last ten years and indicate the year of visit

**28. List all countries which have previously issued you a passport

**29. List your last two places of work, excluding the current one

1.  Name       XEROX

Address     123 BLANK STREET, ST. LOUIS, MO  

Your position SALES REP

Phone number     314-555-1212       

Your supervisor?s full name     JOE  SMITH

Dates of employment    2000-2002 

2.  Name                   

Address            

Your position    

Phone number                      

Your supervisor?s full name 

Dates of employment              

**30. List all educational institutions you ever attended, except high schools

**31. List all professional, civil and charity organizations which you

are (were) a member of, or contribute (contributed) to, or work (worked) with

**32. Do you have any specialized skills, training or experience related to fire-arms and explosives or to nuclear, biological or chemical activities? If ?Yes?, please explain      

**33. Have you ever performed military service? If ?Yes?, indicate the country, branch of service, rank, military occupation and dates of service  NO

**34. Have you ever been involved in an armed conflict, either as a member of the military service or a victim? If ?Yes?, please explain   NO

35. Are any of your relatives mentioned below staying in Russia now? Is he (she) a permanent resident or citizen of Russia? If ?Yes?, indicate that person?s full name, address and status in Russia (citizen of Russia, permanent or temporary resident, visiting, studying, working, etc.)

36. IMPORTANT! EACH APPLICANT MUST READ AND GIVE ANSWERS TO THE FOLLOWING QUESTIONS

A visa may not be issued to persons belonging to specific categories, defined by the Law as undesirable, except in cases when a waiver has been obtained in advance.

Have you ever been arrested or convicted for any offence?

?           Have you ever been sick with a communicable disease of risk for the public or suffered a dangerous physical or mental disorder?

?           Have you ever been refused a Russian visa?

?           Has your Russian visa ever been canceled?

?           Have you ever tried to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false information?

?           Have you ever been  deported from Russia?

While an affirmative answer does not automatically mean ineligibility for a visa, if you answered ?Yes? you will have to appear in person  before a Consular officer.

37. Your permanent address, phone, fax number and E-mail address

Place for photograph

STAPLE

40. Has anyone assisted you in completing this application form? If ?Yes?, have the assisting

person complete item 41

38. Place of work or study (name, address, phone and fax number,

E-mail address), present position

41. Application completed by

39. Name, address and phone number of person or hotel in Russia that you plan to
stay with:

Applicant?s signature, Date

PLEASE SIGN AND DATE

Signature of person completing the form, Date