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QUESTIONNAIRE
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ATTENTION Incorrect information may cause denial
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of visa, denial of permission to cross the Russia border,
’4“•”i“•–]“•—4“™˜išiš ›™œ`bž4Ÿi 4¡ ¢¤£b¥]¥]¦i¦ ¦e§:¦ photograph
or annulment of visa on the Russia territory.
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1. Present citizenship (it you had citizenship of the USSR or Russia, than
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when and why you lost it)
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2 Surname (in capital letters) : = ; <>@?AB3C
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3 First and other names (patronymic names) .O PR.Q3S$. S3.TVUI.W
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4 (if changed, your surname, name (names) and patronymic before the
change)
5 Date of birth: ______/________/ 19___ 6. Sex w&x)y
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7 Purpose of journey to Russia „…†‡ ˆ‰Š)‹Œ3Ž$ ‘’
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8 Russian organizations •—–˜@–

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to be visited
9 Rout of journey  —¡)¢3£¢@¤¥¦R§3¨©3ª«¡
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(names of cities to be visited)

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10 Date of entry 11. Date of ©3¨
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/DMY/ departure /DMY/
12 Passport ¹ 13 º
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14 Index
Ì and name of the tourist group
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15 Place
Ñ of work or study in Belgium Position or status: Address (of your office or institute) : Telephone number
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16 Permanent
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ÜBelgium
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è#é Telephone
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ÛRæ3Û#number
ê é
ÝÞ Þ@àááÞâRÞ ã Þ#äÖå áÞ#ã Þá _______________________
17 Name of health insurance company providing Period of medical coverage
medical coverage for the period of stay in Policy ë _______________________________
Russia (Please check the list of companies From: ______/________/ 200___ Expiry date ______/________/ 200___
approved by the Ministry of Foreign Affairs)
Please attach original for approval
Till: ______/________/ 200___
18 Place
ì Û)Ü
ß ofÚ birth
ÙÛ IfÜæ born inÚ Russia/USSR/
Ù æ Ü
çÖèÖðð
ð
when
ñ æ and
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where-to
Ü ß emigrated
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ï Þ å å å å Þ åå Þ ò
ó å$òÞâ

19 Number
ýþù@ü3ÿ@þù of
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previous
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ù 
öö to Russia Date

û

û ofû the
 latest
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Surname
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û Date

û
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øù birth
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ö Permanent
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address
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20 Children under 16 years
traveling with you


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21 Relatives in Russia
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I hereby certify that all information given by me in this Questionnaire is correct:

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Signature of applicant ________________ Date:____/_____/200__

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