Page:Manual of The Mother Church.djvu/204

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INSTRUCTIONS FOR APPLICATION

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APPLICATION.

I. — (Continued.)

PROPERLY SIGNED AND ENDORSED, ACCORDING TO ARTICLE V, SECT. 2.

FORM 1, — (Continued.)

 I was formerly a member of the ............... denomination, but have definitely severed my connection therewith.

Name ..... Mrs. Jennie W. Field, C.S. .....

Street and Number ..... 18 Forest St., .....

Town or City ..... Chicago, .....

State ..... Ill. .....

Date ..... Jan. 2nd, 1901. .....

 I cordially approve the applicant.

(a) ..... James B. Brown, C.S.D. .....

Countersigned by

DO NOT DETACH.

To the Applicant:  Please fill out the following for the use of the Treasurer of the Church:

Name ..... Mrs. Jennie W. Field, C.S. ..... Street and Number ..... 18 Forest St., ..... Town or City ..... Chicago, ..... State ..... Ill. .....