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[[preprinted]]
Application-Bladensburg Union.
City or Town: State: Month: Date: Year:
^[[Newark N.J. Sept 12 1910.]]
I hereby make application for admission into the Bladensburg Union.
Age last birthday ^[[Not given]] years.
[[signature]] ^[[William Wigginton]] [[/signature]]
Name of applicant.
^[[$5. 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]]