My name is ________________________________ Occupation___________________________ Age _______
Born on. ___________________ Are you Irish by birth or descent? Yes __ No __ What was your mothers maiden name? ______________________________________________ Are you a Roman Catholic? _________
Have you completed your religious duties? ___________ Name of your Parish or Church ________________________
Do you belong to any society to which the Catholic Church is opposed? _____________________
Your Residence: ________________________________________________________________________Apt: _______
City: ___________________________________ State: ______________ Zip Code: _________
Business Address: ________________________________________________________________
Phone # (H) ________________________ Business # _____________ E-Mail Address: _______________
Were you previously a member of the A.O.H., if so, in what City, Town, and State? ___________________________
What was your previous membership number, if available? . _______________________________
What was the reason and date of your withdrawal? . ______________________________________
I do solemnly pledge my sacred word and honor that the answers to the above questions are true.
Signature: _________________________________________________________Dated this _____________day of 20___
PROPOSERS CERTIFICATE:
I hereby certify on my honor as a member of the Ancient Order of Hibernians, Inc., that I am acquainted with the above applicant I know him to be a practical Catholic, and one worthy in every way to become a member of this Order
Signature. ________________________________________________________________
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