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[[preprinted]]
Application-Bladensburg Union.
City or Town: State: Month: Date: Year:
^[[Hyattsville Md Dec 4 1911.]]
I hereby make application for admission into the Bladensburg Union.
Age last birthday ^[[10]] years.
[[signature]] ^[[John Robert Hammond]] [[/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.
^[[Not given]] , M. D. 
[[/preprinted]]