Part 55, page 106

Transcript

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

PARACHUTING CENTER ADULT REGISTRATION FORM

[Form fields, left side:] Pres [illegible] Corl _______ Cal ______ erpir _______ [illegible] Coupon On _______ Date of [illegible] _______ Person Address _______ City _______ [illegible] _______ Zip [illegible] [illegible]

[Form fields, right side:] How did you learn of the center? [Checkboxes:] - Only Own Personal A [guess: Sport] or [guess: Skydive] Movie - [illegible] for Article - [guess: Show] Vehicle - [guess: Yellow] Pages Ad - World Championship 1962 - [illegible] Tourism - Word of Mouth - [illegible] - Other

HOW DID YOU TRAVEL TO CENTER? [illegible] Bus [illegible] Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not now, nor have at any time been, under treatment for any physical infirmity or chronic ailment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:

1. Cardiac or pulmonary condition or disease 5. Nervous disorder 2. Bone or bone [guess: blood] problems 6. Diabetes 3. Fainting spells or convulsions 7. Kidney or related diseases 4. [illegible]

Date: [illegible] / /

SIGN -- TURN FORM OVER -- READ AND COMPLETE OTHER SIDE -- [illegible]

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PARACHUTING CENTER ADULT REGISTRATION FORM

[Form fields, left side:] [illegible] Cal [illegible]

[Form fields, right side:] How did you learn of the center? [Checkboxes:] - Only Own Personal A [guess: Sport] or [guess: Skydive] Movie [illegible] for Article [guess: Show] Vehicle [guess: Yellow] Pages Ad World Championship 1962 [illegible] Tourism Word of Mouth [illegible] Other

HOW DID YOU TRAVEL TO CENTER? Plane Car Bus Other

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I voluntarily certify that I am not now, nor have at any time been, under treatment for any physical infirmity or chronic ailment, or injury of any nature, and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:

1. Cardiac or pulmonary condition or disease 5. Nervous disorder 2. Bone or bone [guess: blood] problems 6. Diabetes 3. Fainting spells or convulsions 7. Kidney or related diseases 4. Proof of [illegible]

Date: [illegible]

SIGN -- FIRST READ AND UNDERSTAND AND HAVING THIS SIDE -- TURN FORM OVER -- READ AND COMPLETE

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DB Cooper-23249

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b6 b7C