Police Emerald Society – Division Number 4

82 Fields Avenue, Buffalo, NY 14210

I hereby apply for membership into the Ancient Order of Hibernians in America, Inc. and agree that my reception and continuance in said Order shall depend upon the truthfulness of my answers to the questions which are hereto attached, which answers are made by me for the purpose of obtaining admission into the Order.

Name_________________________________ Address________________________________________

Occupation____________________________ City_____________________State______ Zip________

Age________ Birthday__________________ Phone (H)________________ (W)__________________

Mother’s Maiden Name_________________ Were you ever a member of the Ancient Order of

Hibernians ?____________________________________

Are You Roman Catholic ? ______________ Number of your Division ? ________________________

Have you complied with your religious duties Cause of your withdrawal? _______________________

Within the past year? ___________________ _______________________________________________

Do you belong to any Society to which the

Catholic Church is opposed? _____________ E Mail address_______________________@_________

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

true. __________________________________Applicant. Dated this___________day of_________,20____

Proposer’s Certificate :

Division President’s :

I hereby certify on my honor as a member of

The Ancient Order of Hibernians, Inc. that I hereby certify that this application has been

I am acquainted with the above applicant. I read by me and that the applicant has been

know him to be a practicing Catholic, and selected into the Order.

One worthy in every way to become a member.

__________________________Proposer’s signature ____________day of ____________, 20_____

__________________________Address ____________________________President

Financial Secretary’s:

I hereby certify that the initiation fee of _____________ has been paid on the

____________Day of ____________, 20_____

____________________________Financial Sec.