1.  Applicant's Full Name:	Sharikoff          Poligraff           K.
                                             Last name                    First                      Middle

2.	Applicant's Date Of Birth:    16               June                        1812
                          		          Day                Month                               Year

     Place of Birth:           Vladivostok                       Primorsky region                           Russia
                                          City/Town                                       District/Province                                     Country

3.  Applicant's Spouse Name:  Sharikoffa               OdnaVtoraya           G.
                                     Last name                           First                Middle

     Spouse Birthdate:     21        January      1854
                        Day            Month              year

      Spouse Place of Birth:     Ussuriysk                Primorsky region                Russia
                                          	   City/Town                           District/Province                        Country

     Unmarried Children Under 21 (if any)/Use a separate sheet if you have more than 2 children

  Child 1:      Sharikoff              Priemysh                         P.
                              Last name                         First                                 Middle

           	     17 November  1917                                       St Petersburg, Len Ob, Russia
             	     Birthdate(day-month-year)                                          Place of Birth (City/Town, Country)

4. Applicant's Mailing Address:        14 Kamikadze Drive, Apt.#1

                                           	                Tmu Tarakan, Primorsky region, 690033

5. Applicant's native country, if different from country of birth:	_____________________

6. Applicant's Signature:	________________________________

Phone:	work:  (011)-7-(4232)-55-77-99       Email: aidite@vse.vjopu
               home: (011)-7-(4232)-11-22-33