Ancient Order of Hiberniansin 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 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 mother's maiden name?______
Are you an active, practicing, Roman Catholic?____ Have you complied with your religious duties?______
What is your Parish?______
Do you belong to any society to which the Catholic Church is opposed?______
Check whether: married [ ] or, single [ ] Wife's first name ______
Home address:______
Town:______State:______Zip:______
Business Address:______
Phone(H):______Business:______E-mail:______
Were you ever a member of the A.O.H. if "yes," in what City or Town and State?______
What was your Membership Number, if available?______
What was the reason and date of your withdrawal?______
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I do pledge my sacred word and honor that the answers I have given to the above questions are true:
Applicant Signature:______
Dated this______ / day of______ / 20______
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PROPOSER'S CERTIFICATE:
I hereby certify on my honor as a member of the Ancient Order of Hibernians that I am acquainted with the above applicant. I know him to be a practical Catholic, and one worth in every way to become a member of this Order.
Proposer's
Signature:______/ PRESIDENT'S CERTIFICATE:
I hereby certify that this application has been read to me at a regular meeting and that the applicant has been elected by the
____day of ______20______
President's
Signature:______
STANDING COMMITTEE:
This committee respectfully reports that we have investigated the qualifications of the above applicant formembership in the AOH, and recommend him for membership.
Signature of
Chairman:______/
FINANCIAL SECRETARY:
I hereby certify that the initiation fee of $______has been paid on the
______day of ______20_____
Financial
Secretary:______