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                                                                                                                        Ancient Order of Hibernians in America,Inc.                                                                                                                                                                                                                                                                                                                       
                                 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 on the truthfulness of my answers to the questions which are hereto attached, which answers are made by me for the purpose of gaining admittance to the Order.
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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___
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. ________________________________________________________________
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 Order and recommend him for said membership.
I hereby certify that this application has been read to me at a regular meeting and that the applicant has been elected by the membership of this division on the
day of _____________20 _______ Signature. ___________________________________________________________
I hereby certify that the initiation fee of $ _______has been paid on the _______day of___ ______20____
Seattle-King County Division 1
201 W. Olympic Pl. Ste. 102
Seattle, WA. 98119-4756
(206) 301-9910