Schedule D.

Age,

Name,

Occupation,

Married or Single,

Residence,

What is your Wife's name?

What is your Wife's age?

What has been the state of your Wife's health these last two years?

What has been the state of your health these last two years?

What was the nature of your last illness?

Have you, or any of your family been subject to Ruptures, Spitting of Blood, Asthma, Gout, or Rheumatism?

Do you know of any hereditary disease to which you may be liable?

Have you been refused admission into any Society in consequence of ill-health or otherwise? page 50

Schedules.

Are you aware of any circumstances which in justice and fairness you ought to communicate to the Society, either in regard to your own or Wife's (if any) state of health which, on reference to the Rules of such, might raise a question as regards your eligibility?

Name it,

Are you aware that if at any time hereafter it should be proved that the answers above given are not correct, you will expose yourself to the liability of being expelled from the Society?

And I hereby agree that this Declaration shall be the ground of Contract between the said Court and myself, and any of the statements herein contained be not true, the sum already paid, or any further sums that may be paid by me to the said Court shall be forfeited, and myself deprived of all benefits or advantages from the said Court and the Order.

And I further declare that I will conform to and abide by all the Rules of the Court and of the Order now in force, or hereafter to be enacted; or submit to the penalties therein contained.

As Witness my hand this_______day of_______18