Michael P. Murphy
11208 Chicago Avenue
Sugar Creek, Mo 64054
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 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.
PLEASE TYPE OR PRINT CLEARLY
My name is: ____________________________________________ Occupation: ___________________________
Address ___________________________________ City ________________
State ________________ Zip _________________
Business Phone (______)__________________ Home Phone (______)__________________
Birthdate: _____/_____/______ Age: _____ Email Address_________________________________________
Are you Irish? Y / N By Birth Descent
What was your mother’s maiden name? _______________________ Are you Roman Catholic? ___________
Have you complied with your religious duties within the past twelve (12) months? __________
Do you belong to any Society to which the Catholic Church is opposed? _________ If yes, which one(s) __________________________________________________________
Name of your parish church _________________________________________________________________________________
Were you ever a member of the Ancient Order of Hibernians, Inc, and if so, in what city, town, or state? ______________________
What was your membership number in that Division? _________ Date of your withdrawal? ______________________
I do solemnly pledge my sacred word and honor that the answers I have given to the above questions are true to the best of my knowledge.
Applicant Signature______________________________________________
Membership Number __________________
Dated this ___________________day of ____________________ , 20_____
Do you have any special training or skills that you would like to share with the Order? What are they?_________________________
We in the Hibernians are ALWAYS looking for volunteers to help carry out our charitable works in the community, the following Committees are available to you, which one(s) would you like to volunteer for or like more information on?
Standing Committee ______ Special Projects _______ Freedom For All Ireland _____ Membership Committee ______ Right to Life ______Children for Peace in Ireland Committe ______
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. I know him to be a practical Catholic, and one worthy in every way to become a member of this Order.
Proposer’s Signature _____________________________________
Address ____________________________________________________________________________________________
DIVISION PRESIDENT’S CERTIFICATE
I hereby certify that this applicant has been read by me at a regular meeting and that the applicant has been elected by the membership of this Division on the ______________________ day of ______________________, 20________
DIVISION PRESIDENT SIGNATURE ______________________________________________
REPORT ON APPLICATION
Your Committee, to whom was referred the application of ___________________________________________ would respectfully report that we have investigated the qualifications of said applicant for membership in the Ancient Order of Hibernians, Inc., and recommend him. COMMITTEE CHAIRMAN SIGNATURE _____________________________________________
FINANCIAL SECRETARY’S CERTIFICATE
I hereby certify that the initiation fee of $ _________has been paid on the _________________day of ______________, 20______
FINANCIAL SECRETARY SIGNATURE__________________________________________
