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[[preprinted]] Application-Bladensburg Union. City or Town: State: Month: Date: Year: ^[[Bladensburg Md. Dec 4. 1911]] I hereby make application for admission into the Bladensburg Union. Age last birthday ^[[18]] years. [[signature]] ^[[Edward Rials.]] [[/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]]