USPA membership application submitted in the name D. B. Cooper (Q39)

A- 45410 164-2111 039 LL APPLICATION TO U.S. PARACHUTE [FBI stamp] ASSOC. LABORATORY N IN NAME D.B. COOPER

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Name: D. B. COOPER Mail Address: C/O YMCA (Please Print or Type) City, State and ZIP Code: TORONTO, CANADA Phone: -- USPA No. -- Age: [blank] Sex: YES [illegible handwriting below Sex field]

FOR USPA USE ONLY: USPA No. _____ b6 b7C Postmark Date _____ Amount _____ (Ck., MO, Cash)

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.

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MEMBERSHIP APPLICATION UNITED STATES PARACHUTE ASSOCIATION A Division of the National Aeronautic Association — P. O. Box 109, Monterey, California 93940 DB Cooper-35761

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: ___[illegible mark]___ Club Affiliation, if any: F.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/JACKER

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 infirmity 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: D.B. Cooper ___ Date: Dec 4 1971 Signature of Witness: [REDACTED] Date: [illegible] /1971

YOUR USPA BENEFITS INCLUDE: Parachutist Magazine monthly, Public Liability/Property Damage Insurance, Representation at all levels of government, Eligibility for USPA and NCPL sanctioned competitions, Discount on NAA Membership, Eligibility for membership in USPA and NCPL affiliated clubs, Eligibility for US/FAI Parachuting Licenses, USPA insignia and credentials, Guidance and assistance in all parachuting activities . . . JOIN NOW!