Residents of the 8th District may purchase a flag from my office. For an additional fee, you have the option of requesting your flags be flown over the United States Capitol on a specific date and receiving an accompanying Certificate from the Architect of the Capitol.

To purchase a flag please print and mail this form and your check or money order to:
(Please make check payable to The Supply Service of Congressman Brad Ellsworth)

The Honorable Brad Ellsworth
Attention: Flag Request
513 Cannon House Office Building
Washington, DC 20515

Your Name: ______________________________________________________  
 

Telephone: (Day) (____)___________________ (Evening) (____)____________

Your Address: ____________________________________________________ 

_________________________________________________________________ 

The following information will be included on a certificate included with the flag: 

Recipient Name (if different from name above):__________________________ 

Recipient Address (if different from address above):______________________ 

________________________________________________________________ 

Number/type of flags desired:


	

		

			

			

			Type 
			
			
			

			

			Quantity 
			
			
			

			

			Total 
			
			
		
		

			

			

			3' x 5' Nylon 
			
			
			

			

			_________ x $9.00 
			
			
			

			

			$__________ 
			
			
		
		

			

			

			3' x 5' Cotton 
			
			
			

			

			_________ x $9.25 
			
			
			

			

			$__________ 
			
			
		
		

			

			

			4' x 6' Nylon 
			
			
			

			

			_________ x $13.50 
			
			
			

			

			$__________ 
			
			
		
		

			

			

			5' x 8' Nylon 
			
			
			

			

			_________ x $18.00 
			
			
			

			

			$__________ 
			
			
		
		

			

			

			5' x 8' Cotton 
			
			
			

			

			_________ x $20.00 
			
			
			

			

			$__________ 
			
			
		
		

			

			

			Flying & Certification 
			
			
			

			

			_________ x $4.05 (per flag) 
			
			
			

			

			$__________ 
			
			
		
		

			

			

			 
			
			
			

			

			 
			
			
		
		

			

			

			GRAND TOTAL 
			
			
			

			

			$__________ 
			
			
		
	

Please fly my flag(s) on the following date:____________________________

If not available, please fly on alternate date:____________________________

Optional Information

Name(s) of Individual(s) that flag will be flown for:_______________________

________________________________________________________________

Occasion for which flag is to be flown:________________________________

_________________________________________________________________