Gordon V. Comer Clerk.

I hereby make application for membership, and subscribe to the
Tenets and the By-Laws of the Church.

My teacher in Christian Science is
...............James B. Brown, C.S.D. ..................

I am not a member of any church, excepting Church of Christ,
Scientist, at ........................


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 ..........................................