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[[preprinted]] 
Application-Bladensburg Union.
CITY OR TOWN: STATE: MONTH: DATE: YEAR: 
^[[Brentwood Prince Geo Md. Aug 30 1912]] 
I hereby make application for admission into the Bladensburg Union. 
Age last birthday ^[[26.]] years.  
[[signature]] ^[[Sydney. M. Davis]] [[/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]]