This transcription has been completed. Contact us with corrections.
[[preprinted]] Application-Bladensburg Union. City or Town: State: Month: Date: Year: ^[[Riverdale Md Dec 4 1911.]] I hereby make application for admission into the Bladensburg Union. Age last birthday ^[[23.]] years. [[signature]] ^[[Flora M Scott.]] [[/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]]