Flags - Print Order Form

Congressman Todd Rokita

Flag Order Request Form

Directions: Please print this order request and mail it with your check to the address below!

You will receive an email confirmation when your flag request is received by my office. If you do not receive a confirmation within 2 weeks of submitting your request, please call my office at (202) 225-5037.

 

Flag Purchased By:

Send Flag To Mailing Address:
[required-purchaser-name] [required-shipto-name]
[required-purchaser-street] [required-shipto-street]
[purchaser-street2] [shipto-street2]
[required-purchaser-city], [required-purchaser-state] [required-shipto-city], [required-shipto-state]
[zip5] [zip4] [shipto-zip5] [shipto-zip4]
Phone: [purchaser-phone] [speech] Phone: [shipto-phone] [speech1]

Shipping cost provided by www.usps.com.

For flags flown over the U.S. Capitol, please use the following information for the certificate, or for multiple flags, use the names and occassions as specified on the attached, user-provided document.

:

[cert-name]

:

[cert-occasion]

:

[cert-date]

Please submit your request at least 6 weeks ahead of your desired date. Payments must be made by check, payable to Congressman Todd Rokita's Office Supply Account.

Checks MUST be for the EXACT amount above, to expedite the process!

Mail the form and payment to:

Congressman Todd Rokita
Attn: Flag Coordinator
236 Cannon HOB
Washington, DC 20515
Phone: (202) 225-5037
Fax:  

For Office Use Only:
Received Request: __________ Received Check: __________ Deposited Check: __________
To Flag Office: __________ From Flag Office: __________ Mailed Flag(s): __________

Return to the flag page.