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[[1/4 page form]] [[preprinted at top, centered, bold, large print]] Application--Bladenburg Union. [[handwritten after above text]] 1934 [[preprinted, small text]] City or Town: State: Month: Date: Year: [[preprinted line for information entry]] [[under "State" heading, handwritten]] Maryland [[under "Month" "Date" and "Year" heading, handwritten]] Dec. 14 1903 [[preprinted under above line, italic, small text first line indented]] I hereby make application for admission into the Bladensburg Union. Age last birthday [[entry line]] years. [[handwritten on above entry line]] 30 [[preprinted signature line, small print, right justified]] [[preprinted under signature line, italic]] Name of Applicant [[preprinted double line across page width matching margins]] [[handwritten on double line under "Name of Applicant"]] Cecil H. Scott [[preprinted under double line, italic, small print, indented]] This certified that the above named applicant is in reasonably good health. [[preprinted signature line with ", M.D." at end, right justified]] [[handwritten signature on above line]] Nelson M. Thomas [[handwritten under signature line]] 1820- S St N.W.