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[[preprinted]]
Application-Bladensburg Union.
City or Town: State: Month: Date: Year:
^[[Bladensburg Md. Aug 3 1910]]
I hereby make application for admission into the Bladensburg Union.
Age last birthday ^[[Not given]] years.
[[signature]] ^[Dr Mattie V. S. Lee.]] [[/signature]]
Name of applicant.
^[[$1. bal due $4 Paid W.E.B.
[[double line]]
This certifies that the above named applicant is in reasonably good health.
^[[Not given]] , M. D. 
[[/preprinted]]