**Congressman Ed Perlmutter**

**FLAG REQUEST FORM**

If you wish, you may order a flag that has been flown over the United
States Capitol. Due to the high-demand, expect to receive your flag a
minimum of six weeks after it has been flown. Please keep this in mind
if you need the flag for a special event.

To order your flag, print and fill out the form below. Mail the
completed form with your payment to the address below.

Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_

Address Flag Should be shipped to:

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

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

City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State: \_\_\_\_\_\_\_\_\_\_ Zip Code:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone (home): ( ) \_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_

Phone (work): ( ) \_\_\_\_\_\_\_\_ -\_\_\_\_\_\_\_\_\_\_

Please indicate the flag size and fabric you would like.

  -------------------- ----------------------- ---------------- -----------
  Flag to be flown                                              
  over the Capitol                                              

  **Flag Type**        **Cost of Flag**        **Quantity**     **Total**

  3x5 Nylon            \$17.25                                   

  3x5 Cotton           \$17.15                                   

  4x6 Nylon            \$21.50                                   

  5x8 Nylon            \$26.00                                   

  5x8 Cotton           \$28.80                                   
  -------------------- ----------------------- ---------------- -----------

(There is an additional \$4.05 fee to fly a flag over the Capitol; this
fee is included in the prices listed above)

  -------------------- ----------------------- ---------------- -----------
  Flag NOT to be flown                                          
  over the Capitol                                              

  **Flag Type**        **Cost of Flag**        **Quantity**     **Total**

  3x5 Nylon            \$13.20                                   

  3x5 Cotton           \$13.10                                   

  4x6 Nylon            \$17.45                                   

  5x8 Nylon            \$21.95                                   

  5x8 Cotton           \$24.75                                   
  -------------------- ----------------------- ---------------- -----------

Please Note: Postage prices are included in the cost of the flag. If
more than one flag is being sent to the same location, the cost of
postage increases.

**For Flags flown over the Capitol please indicate:**

Date Flag should be flown: \_\_\_\_\_\_\_\_\_\_, 200\_\_\_

(If you choose to have a flag flown on a specific date, your order must
be received in the Washington, DC office, at least two weeks prior to
that date)

\_\_\_ Date doesn\'t matter

A certificate of recognition is included with each flag. Please indicate
if the flag is for a particular individual, family, or group, or will
commemorate a special occasion. (If you request more than one flag to be
flown, please indicate which each flag certificate should say.)

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

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

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

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

Please enclose a check with this form for the exact dollar amount shown
above. The check should be made payable to: "Congressman Ed Perlmutter
Office Supply Account" and should be mailed to:

*Congressman Ed Perlmutter*

Attn: Whitney Phillips

415 Cannon House Office Building

Washington, D.C. 20515

For questions or more information concerning Flag requests, please
contact Whitney Phillips in Congressman Perlmutter's Washington, D.C.
office at <whitney.phillips@mail.house.gov>, or 202-225-2645