**Congressman Dan Boren**

216 Cannon House Office Building

Washington, DC 20515

Phone: 202-225-2701

**[Flag Request Form]{.underline}**

> **[Instructions]{.underline}:** Please print this form, enter
> information in space provided, and mail it to the above address along
> with your check made out to---**Congressman Boren Office Supply
> Account**

**[Contact Information]{.underline}**

**Name:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Organization:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Address:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Telephone/Fax:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+--------------+------+-----------------+-------------+--------------+
| **SIZE**     | **\# | **PRICE PER**   | **PRICE     | **TOTAL      |
|              | of** |                 | PER\        | FLAG**       |
|              |      | **NON-FLOWN     | FLOWN       |              |
|              | *    | FLAG**          | FLAG**      | **COST**     |
|              | *Fla |                 |             |              |
|              | gs** |                 |             |              |
+--------------+------+-----------------+-------------+--------------+
| **3'x5'      |      | \$13.20         | \$17.25     | \$           |
| cotton**     |      |                 |             |              |
+--------------+------+-----------------+-------------+--------------+
| **3'x5'      |      | \$12.95         | \$17.00     | \$           |
| nylon**      |      |                 |             |              |
+--------------+------+-----------------+-------------+--------------+
| **4'x6'      |      | \$17.45         | \$21.50     | \$           |
| cotton**     |      |                 |             |              |
+--------------+------+-----------------+-------------+--------------+
| **5'x8'      |      | \$23.95         | \$28.00     | \$           |
| cotton**     |      |                 |             |              |
+--------------+------+-----------------+-------------+--------------+
| **5'x8'      |      | \$21.95         | \$26.00     | \$           |
| nylon**      |      |                 |             |              |
+--------------+------+-----------------+-------------+--------------+
| **TOTALS**   |      | \$              | \$          | \$           |
+--------------+------+-----------------+-------------+--------------+

-   *Due to high demand for flags, please allow up to **[3
    months]{.underline}** for delivery*

-   All totals include postage, which is \$3.95.

> **[Recipient Information (for flags flown over the Capitol
> only)]{.underline}**

-   Please submit your request 3-4 weeks before the date the flag is to
    be flown over the Capitol

> **Name on Certificate:
> \_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Date to be flown:**
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Occasion:**
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Address flag to be delivered to]{.underline}**

**Name:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Address:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_