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[[preprinted]]
Application-Bladensburg Union.
City or Town: State: Month: Date: Year:
^[[Hyattsville Md. Aug 1 1910.]]
I hereby make application for admission into the Bladensburg Union.
Age last birthday ^[[4.]] years.
^[[75
45
[[line]]
20]]
[[signature]] ^[[Dorothy. P. Johnson.]] [[/signature]]
Name of applicant.
^[[50c. bal due $2. Paid W.E.B.
[[double line]]
This certifies that the above named applicant is in reasonably good health.
^[[Not given]] , M. D. 
[[/preprinted]]