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What is your name?: Minor F. Jackson
What is your age? (years): 24
What is your occupation?: Farming
Where is your residence?: Madison, C.H., va.
Where were you born?: Madison, C.H., va.
Are you married?: no
What was your wife's name before marriage?: none
Are you married to more than one woman?: not at all
Have you children?: none
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?: 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: Apr. 10, 1919
Signed : Minor F. Jackson
Witnessed: : Randolph Willis
Witnessed: Strother Scott Sr.