Flag Request Form

(Please Print)

Date of Request ________________

Name ____________________________________________

Address __________________________________________

City, State, Zip Code ________________________________

Telephone Number _________________________________

Flag to be Flown in Honor of ______________________________________________

To Commemorate _______________________________________________________

______________________________________________________________________

Date Flag to be Flown ____________________________________________________

Send Flag to ___________________________________________________________



Size Material Unit Price Total Price
3 feet x 5 feetCotton$9.25$
5 feet x 8 feetCotton$20.00$
3 feet x 5 feetNylon$9.00$
5 feet x 8 feetNylon$18.00$
Flag Certification Fee / per flag $4.05 $
Shipping & Handling / per flag $4.00$
Total Enclosed $

Please make check payable to: "Keeper of the Stationery"

Expect to receive your flag approximately 4 - 6 weeks after the date to be flown.

Please mail this form and your check to:

The Honorable Gordon H. Smith
Attention: Flag Requests
404 Russell Senate Office Building
Washington, DC 20510-3704