Flag Order Form

* Prefix

* First Name

* Last Name

* Address

* City

*State

* Zip Code		+ 4

Phone

* Email

* - Required Field

Indicate the number of which flag(s) you would like:
Please note: flag prices are subject to change.

	3'x5' Nylon @ $9.00
	3'x5' Cotton @ $9.25
	4'x6' Nylon @ $13.50
	5'x8' Nylon @ $18.00
	5'x8' Cotton @ $20.00
	3'x5' Nylon flown over the Capitol @ $13.05
	3'x5' Cotton flown over the Capitol @ $13.30
	4'x6' Nylon flown over the Capitol @ $17.55
	5'x8' Nylon flown over the Capitol @ $22.05
	5'x8' Cotton flown over the Capitol @ $24.05

If you have a date preference, please enter date
(allow 4-6 weeks notice prior to desired date):

Text written on the certificate

** Check should be made payable to: Congressman Mike Rogers Office Supply Account ***

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133 Cannon House Office Building | Washington, D.C. 20515 | Phone: (202) 225-4872 | Fax: (202) 225-5820