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Flag Request Form

My office can provide United States flags to residents of Kentucky's 2nd District.

Optionally, the flags can be flown over the U.S. Capitol Building. Each flag that is flown comes with a certificate detailing the occasion you provide.

Your Name:
Prefix First Name * MI Last Name * Suffix (Jr., Sr.)
* Your Address:
* City: State: Zip:
Phone Number:
* Email:
Recipient's Name:
Prefix * First Name * MI Last Name * Suffix (Jr., Sr.)
* Shipping Address:
* City: State: Zip:

Size Fabric Quantity Flown
over the Capitol		 Quantity NOT Flown
over the Capitol		 TOTAL
3'x5' Nylon @ $13.05 @ $9.00
3'x5' Cotton @ $13.30 @ $9.25
4'x6' Nylon @ $17.55 @ $13.50
5'x8' Nylon @ $22.05 @ $18.00
5'x8' Cotton @ $24.05 @ $20.00
Subtotal
S & H
TOTAL

Date to be Flown: (at least three weeks from this date)

Required certificate text:
This is to certify that the accompanying flag was flown over the United States Capitol on [date] in honor of...
* Continue Message: