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IF YOUR AERIE OFFERS BENEFITS, <br />and you wish to participate, fill out the following <br />DECLARATION OF PHYSICAL CONDITION <br />Give details of any illness, disability, or accident suffered in the last two years. <br />To the best of my knowledge and belief, I am at present in sound health with no deformity, loss or impairment of limb, sight, hearing, or <br />speech. I understand that any benefits to which I may be entitled shall be payable in accordance with, and subject to, the provisions of the <br />By-Laws of the local Aerie in which I become a member, and the Constitution and Statutes of the Fraternal Order of Eagles. I have not suffered <br />from tuberculosis, cancer, or disease of the heart. If so give details. <br />Applicants signature ;Date , <br />First Proposer: ~ Aerie No. ~J <br />Name <br />Second Proposer: Aerie No. ~J <br />Name <br />Grand Aerie I.D. No. { { { { { { { { Address <br />Address <br />City StatelProv. Zip Code <br />City State/Prov. Zip Code <br />,......v~o~ ..,.... ~~~..v...... s <br />APPLICATION APPROVED FOR <br />Beneficial ^ or Non-Beneficial ^ Membership <br />Month .Day Year <br />Application Submitted L_1_I ~~ I I I <br />Elected to Membership ~~ ~~ L_L_.__~ <br />Date Initiated ~~ L~J L~J <br />We, your Committee have interviewed the <br />above-named applicant and recommend that he be <br />^ Accepted ^ Rejected ^ Re-Enrolled <br />for membership in this Order. <br />Secretary <br />I!- I! lj l~'i1 u IS W uCl W L~, ®W ®IS W ®I~ 15 W lt}! L~ 15 ~ Aerie Initiation Fee Receipt <br />Received from Amount Received $ <br />Applicant's Name <br />In payment of Initiation Fee in Aerie No. <br />Received by <br />Date <br />Signature of Sponsor <br />To Txe Aeeucnrir -This is your receipt for payment oJlnitiation Fee only and does not entitle you to any privileges in the Aerie. IJ your application for membership <br />is accepted 6y the Aerie you will be notified of your election to membership. Your OJtuial Receipt identifying you as a paid up member of the Order will be issued to <br />you at the time of your initiation and/or upon payment of dues. <br />DETACH & Glve Thls Portion To Applicant <br />