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What is your name?: Robert L Carter

What is your age? (years): 45 1926 Aug 7

What is your occupation?: farm hand

Where is your residence?: Madison

Where were you born?: Madison

Are you married?: Yes

What was your wife's name before marriage?: William

Are you married to more than one woman?: One

Have you children?: Yes

Do your wife and children enjoy good health?: Yes

Are you sound in body?: Yes

Are you subject to any periodic complaint which is liable to render you unable to follow your usual employment, or which is calculated to shorten life, and thereby render yourself, wife, and children a burden to this Lodge?: No

Will you faithfully obey the laws and submit to all the penalties that may be imposed, should it ever be proved that you have made a false statement?: Yes

Dated:

Signed :

Witnessed: :

Witnessed: