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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]]