Date of Request: _____________

Constituent Making Request (if different than below): ______________________________________________

Phone # For Above Constituent (if different): _____________________________________________________

Name of flag recipient: ( )Mr. ( )Mrs. ( )Ms. ______________________________________________________

Address:__________________________________________________________________________________

__________________________________________________________________________________________

City & State: ____________________________ Zip Code: _________________

Phone Number: Home_____________________ Office ____________________

Size and Quantity Requested:

3 X 5 Nylon (  ) *$17.10 each    |    3 X 5 Cotton (  )*$18.45 each

5 X 8 Nylon (  ) *$27.20 each    |    5 X 8 Cotton (  ) *$31.25 each

4 X 6 Nylon (  ) *$22.70 each

*Flag prices are subject to change.  Please check with a LaHood office to ensure prices are correct.

Total Amount Owed: ______________________

Check Attached: ( ) Yes ( )No  
Comments: ______________________________

Date to be flown: ___________________ Date needed by: _________________

Date to be returned: _________________

Information for Certificate: ______________________________________________________________________

____________________________________________________________________________________________

To Above Address:___

To: Alternate Address:__________________________________________________________________________

To:  LaHood Peoria Office ___     LaHood Jacksonville Office ___     LaHood Springfield Office ___

Date Sent to F.O. ___________ Date Returned ____________

Date Mailed ________________

Please print out the above form and fill it out completely. Checks should be made out to "O.S.S. IL 1840." Questions can be answered at any of our offices. Once completed, mail the form along with your enclosed check to the following address:

Due to the high volume of requests, our office is only able to service Congressman LaHood's constituency and accommodate orders up to five flags. If you do not live in Illinois' 18th District, please contact your member's office, and they will be able to service your request.