Ancient Order of Hibernians Division 19 - Port Washington, NY

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Application for Membership

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 CATHOLIC AND BE OF IRISH HERITAGE BY BIRTH OR DESCENT. (Only Exception: Clergy need not be Irish.)

My Name is:*
FirstLast
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal Code
Home Phone*
Cell Phone
Work Phone
Email*
Occupation*
Date of Birth*
MM
DD
YYYY
Irish by:*
- Birth
- Descent
- Adoption
Mother's Maiden Name*
Are You Catholic?*
- Roman Catholic
- Other Catholic Rite Recognized By the Pope
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
Division of Choice*
I do solemnly pledge my sacred word and honor that the answers I have given to the above questions are true.*
- I Do Pledge
Verification
Name
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