acting in loco parentis) Applicant Name: (Last Name, First Name, Middle Name) Applicant Phone No: Date: (Area Code-XXX-XXXX) (MM/DD/YYYY) Courier Company Name: Please handwrite "Go To Russia" here. Applicant Signature: (If the applicant is under the age of 16, a parent, legal guardian, or person legall

y acting in loco parentis) Applicant Name; EPSTEIN, JEFFREY, EDWARD (Last Name, First Name, Middle Name) Applicant Phone No (Area Code-XXX-XXXX) Courier Company Name: G3 VlsasA Passports, I Applicant Signature: Date: 06/252014 (Mtvl/DD/YrrY) (If the applicant is under the age of 16 the parent (s), legal guardi

loco parentis) Applicant Name: 0- 73-rei -cerr2F\.,t Ent.,O(12.N (Last Name, First Name, Middle Name) Applicant Phone No: (Area Code-XXX-XXXX) Courier Company Name: a) 1O 2LISSDor Applicant Signature: Date: O7 —a5 —001(0 (MM/DD/YYYY) (If the applicant is under the age of 16, a parent, legal guardian, or p

or person legally acting in loco parentis) Applicant Name: CMIE : 711Q 3EFT2a Fuerne__ (Last Name, First Name, Middle Name) Applicant Phone No: Courier Company Name: Date: 05-a5 xDKo (MM/DD/YYYY) 60 IT) (-LISS /A Applicant Signature: (If the applicant is under the age of 16, a parent, legal guardian, or p

cant Name: Epstein, Jeffrey, Edward (Last Name, First Name, Middle Name) Applicant Phone No: Date: 09-19-2016 (Area Code-XXX-XXXX) (MM/DD/YYYY) Courier Company Name: G3 Visas & Passports, Inc. Applicant Signature: (If the applicant is under the age of 16, a parent, legal guardian, or person legally acting in l