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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 ^[[25]] years.
[[signature]] ^[[Eliza Belle Wheeler]] [[/signature]]
Name of applicant.
^[[$1. bal due. $4. W.E.B.]]
[[double line]]
This certifies that the above named applicant is in reasonably good health.
[[signature]] ^[[Not given]] [[/signature]] , M. D. 
[[/preprinted]]