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What is your name?: John Hercules Hill
What is your age? (years): 18 [9 months]
What is your occupation?: [Orsthers] and contraction [construction?]
Where is your residence?: Madison
Where were you born?: Madison
Are you married?: no
What was your wife's name before marriage?:
Are you married to more than one woman?:
Have you children?:
Do your wife and children enjoy good health?:
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?:
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: March 9 1930
Signed : Robert Cambel
Witnessed: : Birdie Scott
Witnessed: E. L. Terrell