APPLICATION FOR MEMBERSHIP

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 admitted to the order.

TO BE A MEMBER YOU MUST BE A PRACTICING ROMAN CATHOLIC AND BE OF IRISH

HERITAGE BY BIRTH OR DESCENT. (Only Exception: Clergy need not be Irish.)

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My Name is: ……………………………………………………………………………………………….…………………….

Address: …………………………………………………………………………………………………………………………

City: ……………………………………………………………. State: …………………………. Zip Code …………………

Occupation: …………………………………………….………………….. Home Phone: …………………………………

E-Mail Address: ……………………………………………………………. Work Phone: …………………………….……

Age …………. Date of Birth ………/………/……… Irish by: Birth ……… Descent ………

Mother's maiden name: …………………………………………………………………………………………………………

Are you a Roman Catholic: Yes …….. No …….. Name of your Parish ……………………………………………….

Have you complied with your religious duties within the past 12 months: Yes …….. No ……..

Do you belong to any Society to which the Catholic Church is opposed: Yes …….. No ……..

Were you ever previously a member of the Ancient Order of Hibernians before Yes …….. No ……..

If you were a member before please give the City, State, Division # and reason for withdrawal

………………………………………………………………………………………………………………………………………

Applicant Signature …………………………………………………………………………… Date ………/………/………

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I hereby certify on my honor as a member that I the applicant is known by me

to be of good character, a practicing Roman Catholic, and worthy to become

a member of the Ancient Order of Hibernians.

Proposer’s Signature ………………………………….……………………………

Date ………/………/………

I hereby certify that this application has been read to me at a regular meeting

and the applicant has been elected a member of this division by the

members present.

President’s Signature ………………………………….……………………………

Date ………/………/………

The Standing Committee has investigated the applicant and recommends

him for membership.

Standing Committee Signature ……………………….……………………………

Date ………/………/………

I hereby certify that the member has paid the initiation fee/dues $...............

Financial Secretary’s Signature …………………….……………………………

Date ………/………/………

Form 41 revised 9/9/03 AOH National Office: 31 Logan St., Auburn, NY 13021 Phone: 315-252-3895 Fax: 315-252 6996