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[[preprinted]]
Application - Bladensburg Union.
City or Town: State: Month: Date: Year:
^[[Hyattsville, Md. July 7, 1913.]]
I hereby make application for admission into the Bladensburg Union.
Age last birthday ^[[4]] years.
^[[$1]] [[signature]] ^[[Sonise Plummer Moss,]] [[/signature]]
Name of Applicant.
[[double line]]
This certifies that the above named applicant is in reasonably good health.
[[signature]] ^[[Mattie V. S. Lee]] [[/signature]] , M. D. 
[[/preprinted]]

Transcription Notes:
Name might be Louise rather than Sonise