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[[preprinted]] Application-Bladensburg Union. City or Town: State: Month: Date: Year: ^[[Bladensburg Md. July. 30 1910.]] I hereby make application for admission into the Bladensburg Union. Age last birthday ^[[44.]] years. [[signature]] ^[[Bettie Davis]] [[/signature]] Name of applicant. ^[[$1. bal $4: Paid W.E.B.]] [[double line]] This certifies that the above named applicant is in reasonably good health. [[signature]] ^[[Not given.]] [[/signature]] , M. D. [[/preprinted]]