### Congressman J. Randy Forbes

Virginia's Fourth Congressional District

**Flag Request Form**

*Updated 8/22/2007*

### 

### 

### Section A -- Requesting Party Information 

  ---------------------------------- ------------------------------------
  **Today's Date**                   

  **Name**                           

  **Address**                        **City/Zip**

  **Phone** (   )                    **Email**      

                                     
  ---------------------------------- ------------------------------------

### Section B -- Flying Instructions 

*Certificates will be printed exactly as information is given below.*

+-----------------------------------------------------------------------+
| 1\) Is the flag to be flown over the Capitol? Yes No (If no, please   |
| skip to Section C)                                                    |
+-----------------------------------------------------------------------+
| 2\) To be flown in Memory of: Honor of:                               |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| 3\) On the occasion of:                                               |
+-----------------------------------------------------------------------+
| 4\) Date to be flown:       ASAP                                      |
+-----------------------------------------------------------------------+

*Orders must be received at least **three weeks** prior to date of
flying. Orders received after the three-week deadline may not be flown
on the date specified, but will be flown as soon as possible. Special
requests will be handled on an individual basis.*

##### Section C -- Quantity and Payment Information

+---------------------------------------+---------+--------------------+
| **Flag Type**                         | **Qua   | **Subtotal**       |
|                                       | ntity** |                    |
+---------------------------------------+---------+--------------------+
| 3X5 Nylon (\$9.00 each)               |         | \$                 |
+---------------------------------------+---------+--------------------+
| 4X6 Nylon (\$13.50 each)              |         | \$                 |
+---------------------------------------+---------+--------------------+
| 5X8 Nylon (\$18.00 each)              |         | \$                 |
+---------------------------------------+---------+--------------------+
| Capitol Flying Fee (\$4.05 per flag)  |         | \$                 |
+---------------------------------------+---------+--------------------+
| Postage (\$3.20 per flag)             |         | \$                 |
+---------------------------------------+---------+--------------------+
| ## TOTAL                              |         | \$                 |
+---------------------------------------+---------+--------------------+
| ## Check Number                       |         |                    |
+---------------------------------------+---------+--------------------+

*Checks must be: a) Payable to the "Office Supply Service Account of J.
Randy Forbes"; b) Written for the exact amount; c) Dated on or around
the flying date. **Checks will not be cashed until order is shipped.***

### Section D -- Shipping Instructions

  ---------------------------------- ------------------------------------
  **Name**                           

  **Address**                        **City/Zip**      
  ---------------------------------- ------------------------------------

Allow an additional 6-8 weeks from flying date for the Capitol
processing and shipping.

#### Section E -- Submission 

**Mail request and check to Congressman Forbes' nearest district office.
Please do not mail flag requests to Washington, DC as mail delays will
add an additional 4 weeks processing time to your flag request. Thank
you!**