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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]]