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^[[Join for $500]]
[[preprinted]]
Application-Bladensburg Union.
City or Town: State: Month: Date: Year:
^[[Bladensburg Md. [[strikethrough]] July [[/strikethrough]] Nov 2 [[strikethrough]] 1905 [[/strikethrough]] 1925.]]
I hereby make application for admission into the Bladensburg Union.
Age last birthday ^[[20]] years.
^[[$100]] [[signature]] ^[[George Thomas Green.]] [[/signature]]
Name of applicant.
[[double line]]
This certifies that the above named applicant is in reasonably good health.
[[signature]] ^[[H. T. Willis]] [[/signature]] , M. D. 
[[/preprinted]]