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
MEMBERSHIP FEE $15.00	OVERSEAS $20.00	SEND TO: BILL WOOD, (TOP JOS), 324 N. Old Grove Rd, Lot 23, Greenville, SC 29605
JUMPERS OVER SEVENTY