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[[preprinted]] Application-Bladensburg Union. City or Town: State: Month: Date: Year: ^[[Hyattsville Md. Sept 2. 1910]] I hereby make application for admission into the Bladensburg Union. Age last birthday ^[[9.]] years. [[signature]] ^[[Josephine Ruffin.]] [[/signature]] Name of applicant. ^[[50. bal due $2. 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]]