DO NOT DETACH.

To the applicant: Name …… Mrs. Jennie W. Field, C.S. …… Please fill out the Street and Number … 18 Forest St., …….. following for the use Town or City ………… Chicago, ………. of the Treasurer of State ………………………. Ill …… the Church:

Application I

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

If you have been taught by a loyal student who has taken a degree at the Massachusetts Metaphysical College, or by one who has passed an examination by the Board of Education, fill this blank.