USPA membership application submitted in the name 'D. B. Cooper' (c/o YMCA, Toronto)

B. Personal Data: No. of Parachute Jumps: Military S/L: 0 Sport S/L: 0 Freefall 1 Total Sport Jumps: 1 (727) No. of Years a Member of USPA: ____ Armed Forces Served with, if any: ____ Club Affiliation, if any: P.B.I SPORT PARA CLUB Conference in which drop zone or club is located: NORTHWEST US/FAI Parachuting License held, if any (Class & Number): ____ Business/Occupation: PROFESSIONAL H I THACKER

C. Medical Certificate: USPA recommends that all parachutists receive an FAA Class III Medical examination or be examined by a medical physician prior to making parachute jumps. In lieu of these certifications, each member must complete the following medical certificate if they are to participate in parachute jumps.

Date of Birth: [redacted] Height: 6' Weight: 167 Color of Hair: BRN Color of Eyes: BRN

I hereby certify that I have no physical infirmity, am not under treatment for any physical in- firmity or chronic ailment, or injury of any nature; and that I have never been treated for any of the following: 1. Cardiac or pulmonary condition or disease 4. Nervous disorder 2. Diabetes 5. Kidney or related diseases 3. Fainting spells or convulsions 6. High or Low blood pressure

Signature of Applicant: [signature present] Date: Dec 11 1971 Signature of Witness: [signature present] Date: [guess: Dec] [illegible] /1/71

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YOUR USPA BENEFITS INCLUDE: Parachutist Magazine, [guess: $1] < Liability/Property Damage Insurance, Repre- [partially illegible] ...sanctioned competition/show, Discount on NAA Mem- ...in PA and NYC, affiliated clubs, Eng [guess: Mfrs] list, US/FAI Parachuting & [guess: licenses], ...and credentials, Guidance and assistance in all parachuting activities JOIN NOW!

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[partially illegible stamps] DEC 3 1971 [guess: SEATTLE] [illegible additional stamp text]

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DB Cooper-5298

FOR USPA USE ONLY: USPA No.___ Postmark Date___ Amount___ (Ck., MO., Cash)

Name: D. B. COOPER (Please Print or Type) Mail Address: c/o YMCA. CANADA TORONTO City, State and ZIP Code___ USPA No. -- Phone -- Age___ Sex: YES [illegible]

A. Application: I hereby apply for membership in the United States Parachute Association as indicated below. (Please Note: Membership includes annual license validation.) CHECK ONE: ☐ New Membership — $15.00 ☐ Current Member Renewal — $12.00 ☐ Delinquent Member Renewal — $15.00 ☐ Family Membership Plan: Two members of an immediate family may join USPA at a $2.00 reduction in the total cost of two regular memberships provided they join at the same time and reside at the same address. ☒ Lifetime Membership: $200.00. Includes all regular membership benefits for life. Note: Membership, PL/PD Insurance, PARACHUTIST magazine subscription and other membership benefits expire on the last day of the twelfth month following the month in which the membership is issued. Membership dues are non-refundable. Please sign and complete all applicable information on reverse side.

MEMBERSHIP APPLICATION UNITED STATES PARACHUTE ASSOCIATION A Division of the National Aeronautic Association — P. O. Box 109, Monterey, California 93940

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[Upside-down bleed-through text from reverse side of form, partially legible:] MEMBERSHIP SECRETARY N. S. [guess: P.] A. P. O. BOX 109 [guess: MONTEREY, CALIFORNIA] [illegible additional lines]

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DB Cooper-5299