Part 81, page 292

Transcript

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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!