Membership Application Form

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 which are hereto attached, which answers are made by me for the purpose of gaining admittance to the Order.

...................................................PLEASE TYPE OR PRINT CLEARLY.........................................

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 widthdrawal?_______________________________

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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 for membership 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:____________________

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If you seek to enter our organization, please fill out the attached application and
return it to the Division. You will be contacted.

COL. THOMAS J. CUNNINGHAM, JR. DIVISION
Ancient Order of Hibernians
P.O.Box 1486, Ashburn, Va. 20146
Steve Hanley, President (703) 729-9126
Mike Hippchen, Vice President (703) 737-0099

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For additional Information about this website E-mail to: Steve Hanley, Mike Hippchen
Last Revised on January 1, 2003.