Fill and Sign the Authorization for Release of Protected Health the Little Clinic Form

VISA APPLICATION IMPORTANT! Please print or type using ballpoint pen 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 6. Purpose of visit If you formerly had USSR or Russian citizenship, please indicate when and why you lost it 7. Visa category and type 2. Last name (as in passport) 8. Number of entries 1 3. First and middle names (as in passport) 9.Date of entry (dd/mm/yy) 4. Date of birth (dd/mm/yy) 11. Number of previous trips to Russia? Date of last trip to Russia (dd/mm/yy) from 5. Sex M 12. Passport number 13. Type of passport diplomatic F Passport issued by official 2 Date of issue (dd/mm/yy) tourist seaman’s passport multiple 10. Date of departure (dd/mm/yy) to Valid until (dd/mm/yy) alien’s travel document other (please specify) 14. Russian organization to be visited (for tourists – name and reference number of the tourist organization, for business – name and city of the organization, for privates – surname, first name and the address of person will be visited) 15. Itinerary (places to be visited) **16. Do you have a medical insurance policy valid in Russia? (please specify) 17. Who will pay for you trip to and stay in Russia? 18. Marital status married single (never married) divorced 19. Spouse’s full name (even if divorced or separated, please indicate maiden name if applicable) separated widowed 20. Spouse’s date of birth (dd/mm/yy) 21. Spouse’s place of birth **22. Your father’s full name 24. Have you ever been issued a Russian visa? yes When? (dd/mm/yy) **23. Your mother’s full name Where? no **25. Have you ever lost your passport or had one stolen? **26. List all countries you have visited in the last ten years and indicate the year of visit yes no **27. List all countries which have previously issued you a passport **28. List your last two places of work, excluding the current one 1. Name Phone number Address Your supervisor’s full name Your position Dates of employment 2. Name (mm/yy) (mm/yy) (mm/yy) (mm/yy) Phone number Address Your supervisor’s full name Your position Dates of employment ** - Not to be filled by holders of diplomatic and official passports **29. List all educational institutions you ever attended, except high schools 1. Name Address and phone number Course of study Dates of admission and graduation (mm/yy) 2. Name (mm/yy) Address and phone number Course of study Dates of admission and graduation (mm/yy) **30. List all professional, civil and charity organizations which you are (were) a member of, or contribute (contributed) to, work (worked) with (mm/yy) **31. 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 **32. Have ever performed military service? If “Yes”, indicate the country, branch of service, rank, military occupation and dates of service **33. Have you ever been involved in armed conflict, either as member of military service or a victim? If «Yes», please explain 34. IMPORTANT! EACH APPLICANT MUST READ AND GIVE ANSWERS TO THE FOLLOWING QUESTIONS A visa may not be issued to person belonging to specified categories, defined by the Law as undesirable, except in case when a waiver has been obtained in advance Have you ever been arrested or convicted any offence? yes When? (dd/mm/yy) Where? no Have you ever been sick with the communicable disease of risk for the public or suffered a dangerous physical or mental disorder? Have you ever been abused drugs or been a drug-addict? Have you ever been refused a Russian visa? yes When? (dd/mm/yy) Where? Has your Russian visa ever been canceled? yes When? (dd/mm/yy) yes no no Where? no Have you ever tried to obtain or assisted others to obtain a Russian visa or enter Russia by providing misleading or false information? yes no Have you ever overstayed your Russian visa or stayed unlawfully in Russia? yes no Have you ever been deported from Russia? yes When? (dd/mm/yy) Where? no 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. 35. Name, address and phone number of person or hotel in Russia that you plan to stay with 36. Has anyone assisted you in completing this application form? If «Yes», have the assisting person complete item 37 37. Application completed by: Name yes no Relationship to applicant Address 38. Other surnames used (maiden, religious, etc.) 39. Home address (house number, street name, flat number, town, post code, phone number, E-mail) Please glue passport size photo here 40. Place of birth (if born in Russia, please indicate when and to what country you emigrated) 41. Present occupation, name and address of employer or school (for students) (Name, address, phone number, e-mail) I declare that the data given in the VISA APPLICATION are correct. I agree, that my personal data will be processed and transferred in an electronic kind for decision-making on issue of visa. Date (dd/mm/yy), personal signature 42. Are any of your relatives staying in Russia now? (full name, patronymic, date of birth, permanent address)