I hereby apply for admission into the Ancient Order of Hibernians In America, Inc., and agree that my reception and continuance in said Order shall depend upon the truthfulness of my answers to the questions which are hereto attached, which answers are made by me for the purpose of obtaining admission to the Order.

My name is_______________________________________ Occupation_________________ Age_________ Born on_____/____/_____ What was your mother's maiden name?_____________
Are you a Roman Catholic?_______
Have you complied with your religious duties within the past twelve months?_____
Do you belong to any Society to which the Catholic Church is opposed?_____
Name of your parish church _______________________
Residence______________________________________
City_______________________State______Zip__________ Phone_____________
Business Name and Address _______________________________________________________
E-mail address_________________________________
Phone_________________ Are you Irish by birth_____descent_____(check one)
Were you ever a member of the Ancient Order of Hibernians, Inc., and if so, in what city or town or state?
__________________________________________________________________
What was your membership number in that Division?_________
What was the cause of your withdraw? __________________________ Date of withdraw___/___/___
I do solemnly pledge my sacred word and honor that the answers I have given to the above questions are true.

X_________________________________________ On____/____/____

Proposers Certificate-I hereby certify on my honor as a member of the Ancient Order Hibernians Inc., that I am acquainted with the above applicant. I know him to be a practicing Catholic and one worthy in every way to become a member of this order .

__________________________________Proposer (Print Name)

__________________________________Proposer (Signature)

__________________________________Proposer’s Address

Your Committee, to whom was referred the application of
________________________________________
would respectfully report that we have investigated the qualifications of said applicant for membership in the Ancient Order of Hibernians, Inc., and recommend him.
_______________________________________

_______________________________________
Committee

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DIVISION PRESIDENT'S CERTIFICATE

I hereby certify that this application has been read by me at a regular meeting and that the applicant has been elected by the membership of the Division on _____/_____/_____

Signed ___________________________________
President

I hereby certify that the initiation fee of $___________ has been paid on ____/____/____

Signed___________________________________
Financial Secretary