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^[[1929]]
[[preprinted]]
Application - Bladensburg Union.

City or Town: ^[[Bladensburg]] 
State: ^[[Md]]
Month: ^[[Feb.]] ^[[July]]
Date: ^[[23]]
Year: ^[[1912.]]

I hereby make application for admission into the Bladensburg Union.

Age last birthday. ^[[seven - 7]] years

^[[Theodore Henry Mason.]]
Name of Applicant.
[[double line]]

This certifies that the above-named applicant is in reasonably good health.

^[[Geo H Gates]], M. D.
[[/preprinted]]