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[[preprinted]] Application-Bladensburg Union.

CITY OR TOWN:|STATE:|MONTH:|DATE:|YEAR:| 
[[/preprinted]] 

[[dotted underline]] Hyattsville| Md| Nov| 11| 1910 [[/dotted underline]] 

[[preprinted italics]] I hereby make application for admission into the Bladensburg Union. 
Age last birthday [[dotted underline]] ^[[5]][[/dotted underline]] years. [[/preprinted italics]] 

[[dotted underline]] ^[[signature]] Lena Ruffin [[/dotted underline]] [[/signature]][[preprinted italics]] Name of Applicant. [[/preprinted]] [[/dotted underline]] 

^[[50 bal due $2. Paid W.E.B]]

[[double line]]

[[preprinted italics]] This certifies that the above named applicant is in reasonably good health. [[/preprinted italics]]

[[dotted underline]] ^[[signature]] Not given [[/signature]], M.D. [[/dotted underline]]