Bold text denotes required information.

Name
Address
Phone	(H)  (W)
If flag is to be mailed elsewhere, please provide the following:
Name
Address
Please check all applicable boxes. When ordering, please consider flag use when choosing a fabric: nylon flags are better suited to outdoor flight, and cotton is preferable for flags that will be stored
3 x 5 Nylon	0 1 2 3 4 5 Number Ordered
4 x 6 Nylon	0 1 2 3 4 5 Number Ordered
5 x 8 Nylon	0 1 2 3 4 5 Number Ordered
3 x 5 Cotton	0 1 2 3 4 5 Number Ordered
5 x 8 Cotton	0 1 2 3 4 5 Number Ordered
Would you like to have the flag(s) flown over the U.S. Capitol?	Yes No
If yes, what date is the flag to be flown?	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
If yes, flag is to be flown for (name of person and event):

Your check or money order should be made payable to "Keeper of the Stationery."  Your request cannot be processed until payment is received.*

Please send payment and form to:

The Honorable Charles E. Schumer
United States Senate
Washington DC  20510
ATTN:  Flag Coordinator

*Please allow approximately eight weeks for processing and delivery.  Should you have any questions, please call the office at (202) 224-6542.