Part 17, page 464

Transcript

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

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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b6 b7C

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DB Cooper-5298