Please return to:
Senator Ken Salazar
702 Hart Senate Office Building
Washington, D.C. 20510
Attention: Jeffrey Phillips

1. Please print out this form, fill it in, attach a check for the correct amount and mail it to the address at the top of the page. The check should be made out to "Keeper of the Stationery."

Name: _______________________   Street: _______________________ 
City: _______________________     State: ____    Zip: ___________
Phone: (Day) _______________________     (Evening) _______________________ 

2. If you would like to have the flag(s) flown over the Capitol and receive a certificate, please fill in the section below and include the flying and certification charge.

Flag(s) to be flown for: _______________________ 
Occasion (if any): _______________________ 
Date you would like your flag(s) flown over the Capitol (if applicable): ________________

3. If you would like the flag(s) mailed to someone other than the above name, please fill in the section below.
Name: _______________________    Street: _______________________ 
City: _______________________     State: ____    Zip: ___________
 
4. Select the type and quantity of flag(s) you would like to purchase.

Type of flags:             

Quantity:

Total:

3 x 5 Nylon Flag

________ x $9.00 =

$ ________

3 x 5 Cotton Flag

________ x $9.25 =

$ ________

5 x 8 Nylon Flag

________ x $18.00 =

$ ________

5 x 8 Cotton Flag

________ x $20.00 =

$ ________

Flying Fee

________ x $4.05 (per flag) =

$ ________

Shipping & Handling Fee ________ x $4.00 (per flag) =
$ ________
   
$ ________
 Grand Total