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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]]