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eet ele nln nin Nash tna Tat pts N Re han el ae ne on . ; . ’ whe SE : . xt yt: ‘ ee ee * = mt ae and tnt ei? 1 wee! Fa Penn , aud. an ar oes B. Personal Data: No. of Parachute Jumps: Arita $ft: © Sport Oo. Freefali__f.__ Total Spore Jumpi: ts /_. No, of Years a Member of USPA: Armed Forces Served with, if any: Club Aftitiation, if any: _ FAB. Sear PARA_< LEE Conference in which drop zone or club is located: —MEATHW ESL. US/FAI Parachuting License held, if any (Class & Number}: Bininoss/Occapution: PROEESSLOWAL.. HL PHCRER C. Medicat Certificates USPA recommends that ail parachutists receive am FAA Class ffl Medicaf examination of be examined by a medital physician prior to making patachute jumps. In heu of these certifications, cach member must complete the following medical ceetificate if they are to patticipate Cate of git toh 6 weigh ZZ2- Color of Hair BAN Color of EyesZAAL Thereby certify that } have no physical infirmity, am not under treatment for any physical in- tirmnity or chrome ailment, or injury of any mature; and that ! have never been treated for any of the following: Y Cardiac of pulmonary condition or disease 4. Nervous disorder 2. Diabetes & Kidney of eclated diseases 3 Faintien spcilé ce conwuls &. Fhgh ce Low blood pressure A } Signature of Applicant: ae A Cth “ . Dste: he FL, ti) aa Sionature of Witness. Jae eer Def LL EDL your UPA, sunesirs ince Dt: Pav. 3 yb * £ Virunty{Property Dgerace ‘eutarce, Fepre~ SAE a ad Gaetneeet Eakin ty He sanctioned compention Gero" of NAA Mew. Dep Po ty Gwe ere rs oun 0 PA and NPL alts ated pee fing ity ter UsfFas Paratruing J cose, wi we mee re Lrecestiats, GuGarce and assstatce a: Sl pavacreteg xt ites GIN NOW? Seow DB Cooper-5298