Name ____________________________________

Address __________________________________

City _____________ State ______ Zip __________

Phone ____________________________________

Are you a Roman Catholic? ____________________

Have you complied with your religious duties within

the past twelve months? _______________________

Please check qualifications for membership:

Irish by Birth __________ Decent ______________

Wife of an AOH member _____________________

Mother of an AOH member ___________________

Mother of a Junior member, LAOH _____________

Parish: ___________________________________

Occupation _________________________________

Business Address ____________________________

Date of Birth ________________________________

Were you ever a member of the LAOH and if so, in

what city/town and state? ______________________

What was the number of your Division? __________

What was the cause of your withdrawal? __________

____________________________________________

Do you belong to any society to which the Catholic

Church is opposed? __________________________

SPONSOR: _________________________________

I heard about the organization throught ___________

____________________________________________

I pledge that the answers to the questions are true: __________________________________________________ Signature of Applicant