Congressman Pedro Pierluisi

Representing Puerto Rico

U.S. Flag Request Form

Instructions: Complete and print the flag request form. Each U.S. flag comes with a certificate of authenticity. The certificate can include a personalized message for an event and/or person
Todays Date:_________________________ Office-only Received by:__________________________

Purchasers Name:_______________________________________________________________________ Address:_______________________________________________________________________________ City:__________________________________________ , PUERTO RICO Daytime Phone Number :_________________________ Email:_________________________________________________________________________________
*Please note: flag prices are subject to change. Size 3'x5' 3'x5' 4'x6' 5'x8' 5'x8' Material Nylon Cotton Nylon Nylon Cotton Quantity Flown Over the Capitol* _____ @ $13.05 _____ @ $13.30 _____ @ $17.55 _____ @ $22.05 _____ @ $24.05 Quantity NOT Flown Over the Capitol _____ @ $9.00 _____ @ $9.25 _____ @ $13.50 _____ @ $18.00 _____ @ $20.00

Zip:_____________________

TOTAL (please add total): $____________ *If you choose to have your flag flown over the United States Capitol, please complete the following information for the certificate. If you have multiple flags to fly, they must all be flown on the same date. If you have multiple flags to fly on the same date, and you would like different names and/or occasions to appear on each certificate, please leave the name and occasion information below blank, and use a separate document to enclose that information. Flag will be presented to (name as it should appear on the certificate):_______________________ Personalized Message:____________________________________________________________ (Please limit the personal message to no more than three sentences) Requested date for flag to be flown**:________________________________________________ **Flags can also be flown on a specific date. Please provide at least three days advance notice to allow time to fly the flag on the requested date Please submit your request at least five weeks ahead of your desired date. Allow at least 6 weeks for processing
Please mail your completed flag request form(s) and check to Congressman Pedro Pierluisis, DC office at: Office of Rep. Pedro Pierluisi, 1218 Longworth HOB, Washington, D.C. 20515. Checks for payment of all flag orders should be in the exact amount, made out to: Pedro Pierluisi Office Supply Account.