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 following questions which are made by me for the purpose of gaining admittance to the order.

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My Name is ________________________________________ Age ________ Birthday M/D/YR _____________

Are you Irish by birth or descent ?_________ Are you a Roman Catholic ?____________ Are you divorced ? ____________

Have you complied with your religious duties ?______ Name of your Parish or Church?_________________________________

Do you belong to any society to which the Catholic Church is opposed?______________________________________________

Where you ever a member of the A.O.H., if so, in what City and State? ) _____________________________________________

What was your previous membership number? (if available) ___________________________________

What was the reason for your withdrawal? _____________________________________________________________________

Your Current Residence __________________________________________________________________________________ _

City ________________________________________ State ______________ Zip Code _____________

Home Phone # _______________________________ Home E-Mail Address ____________________________________

Occupation _______________________________ Are You Self-Employed Yes ____ No ___

If yes, your business name ____________________________ OR your employer______________________________________

Business Address City __________________________ State ________ Zip Code _____________

Business Phone # ______________________________ Business E-Mail Address _____________________________________

I do solemnly pledge my sacred word and honor that the answers I have given to the above questions are true.

Signed_____________________________________ and dated this _____day of _____________ in the year ________.

PROPOSER'S 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, and know him to be a practical Catholic, and one worthy in every way to become a member of this Order.

Signature __________________________ Print Name _____________________________

An application fee of $45.00, or $50 if a reinstatement, must accompany this application. Checks should be made payable to the Ancient Order of Hibernians. DATE PAID ___________ CASH ___ CHECK # ________ CHECK DATE ___________

Division Readings:1st Date_______ , 2nd Date________, Shamrock Degree Date _______, Major Degree Date______________

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Standing Committee: Respectfully reports that we have investigated the qualifications of said applicant for membership in the Order and recommend him for said membership. Signature ______________________________ Date ___________ Financial Secretary: I hereby certify that the initiation fee of $________ has been paid on the Date _______________ Signature ______________________________ Date ______________________________ 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 membership of this division on this _____day of _____________ in the year ________. Signature ______________________________