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[[preprinted form]]
[[image - drawing of two hand clasping in a handshake]]

APPLICATION BLANK - BLADENSBURG UNION

I hereby make application for admission in The Blandensburg Union.

Name ^[[George Vannester Ford,]]
Street ^[[216 Tenth St. N.E.]]
City or State ^[[Washington 2. D.C.]]
Age last birthday ^[[42]]
Month ^[[Nov. 25]]
Year ^[[1906]]
Beneficiary [[blank line]]

1. Voucher ^[[H. V. Plummer  Chmn  Board of Directors]]
2. Voucher ^[[Rosa E. Plummer]]
[[double line]] 

This certifies that the above-named applicant is in good health.
^[[Wm. W. Spiller]] M.D.
^[[421 - 23d Pl. N.E.]]
[[/preprinted form]]