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[[preprinted form]]

Application - Bladensburg Union.

CITY OR TOWN: ^[[Hyattsville]]
STATE: ^[[Md.]]
MONTH: ^[[Oct]]
DATE: ^[[3.]]
YEAR: ^[[1910.]]

I hereby make application for admission into the Bladensburg Union.

Age last birthday ^[[18.]] years.

^[[Addie F Hammond.]]
Name of Applicant.

^[[$1.tal.due$4: Paid WEB.]]
[[double line]]

This certifies that the above named applicant is in reasonably good health.
^[[not given.]], M. D.

[[/preprinted form]]