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 on the truthfulness of my answers to the questions which are hereto attached, which answers are made by me for the purpose of gaining admittance to the Order.  
……………………………Please type or print clearly………………………………
My name is _________________________________Occupation___________________________________

Age_________ Born on___________ Are you Irish by birth or descent?   Yes _____ No _______________

What was your mother’s maiden name? _______________________________________________________

Are you a Roman Catholic? ________ Have you complied with your religious duties? __________________

Name of you Parish or Church ______________________________________________________________

Do you belong to any society to which the Catholic Church is opposed? _____________________________

Your Residence: ____________________________________________________________________________

City: ___________________________  State: _____________________  Zip Code ___________________

Business address: __________________________________________________________________________

Phone # (H) __________________________________ Business # (B) _______________________________

Were you ever previously a member of the A.O.H., if so, in what City or Town and State? _______________


What was your previous membership number, if available? _________________________________________

What was the reason and 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.  

Signature: ________________________________________

Dated this _____________ day of ________________________ 20 ________



I herby 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.

Signature ________________________________   


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 Order and recomment him for said membership.

Signature __________________________________


I hereby certify that this application has been read to me at a regular meeting and that the applicant has been elected by the membership of this division on the

________ day of __________20 ________    

Signed ________________________________


I hereby certify that the initiation fee of $__________ has been paid on the _______ day of __________ 20 _____

Signed _______________________________________ 

AOH National office: 31 Logan St., Auburn, NY 13021

Phone (315) 252-3895  - FAX (315) 252-6966