NAME – First – Middle Initial - Last							JOS NO.
STREET ADDRESS			CITY
STATE			ZIP-CODE		TELEPHONE
CHANGE OF ADDRESS - STREET			CITY
STATE			ZIP-CODE		TELEPHONE
DATE OF BIRTH
OCCUPATION
NUMBER OF JUMPS                               AS OF				USPA LICENSE		USPA MEMBER NO.
CLUB AFFILIATION		E-MAIL ADDRESS
MEMBERSHIP FEE $15.00	OVERSEAS $20.00		SEND TO: Bob Deen, TOP JOS, 5158 Woodrun on Tillery, Mt Gilead, NC 27306 USA
JUMPERS OVER SEVENTY