Part 101, page 216

Transcript

The scan is the source; the transcript is machine-generated from it.

B. Personal Data: No. of Parachute Jumps: Military S/L: O Freefall: Total Sport Jumps, if any: 1(727) No. of Years a Member of USPA: _____ Sport S/L: O Armed Forces Served with, if any: F.B.I Club Affiliation, if any: SPORT PARA CLUB Conference in which drop zone or club is located: NORTHWEST US/FAI Parachuting License held, if any (Class & Number): _____ Business/Occupation: PROFE[guess: SSIONAL] [illegible]

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: [illegible] Height: 6__ Weight: 1[guess: 6]2 Color of Hair: BRN Color of Eyes: BR[guess: N] 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 2. [Diabetes or similar — illegible] 3. Fainting spells or convulsions 4. Nervous disorder 5. Kidney or related diseases 6. High or Low blood pressure

Signature of Applicant: [redacted — b6/b7C] Signature of Witness: [redacted — b6/b7C] Date: Dec 11 1971

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YOUR USPA BENEFITS INCLUDE: [partially illegible] ...membership in USPA and [illegible] Eligibility for [illegible] and [guess: LOCAL] Liability/Property Damage Insurance, Repre- [illegible] and credentials, Guidance and assistance in all parachuting activities. Eligibility for competitions, Discount on [illegible] parachuting Licenses. JOIN NOW!

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SEARCHED _____ INDEXED _____ SERIALIZED _____ FILED _____ DEC 3 0 1971 FBI — SEATTLE

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DB COOPER-45679

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b6 b7C