Flag Request Form

Please return this form, along with a check or money order made out to: "Keeper of the Stationery", to:

Senator E. Benjamin Nelson
7602 Pacific St., Suite 205
Omaha, NE 68114
(attn: Flag Coordinator)

Your name and phone number: _________________________________________

Your address: _______________________________________________________

The following information will be included on a certificate included with the flag:

Flag will be presented to: ______________________________________________

Address flag should be mailed to: ________________________________________

___________________________________________________________________

Occasion (if any):_____________________________________________________

Date flag you wish the flag to be flown (if applicable):_________________________

Number/type of flags desired:

Type
Quantity
Total
3' x 5' Nylon
__________ x $9.00
$____________
3' x 5' Cotton
__________ x $9.25
$____________
5' x 8' Nylon
_________ x $18.00
$____________
5' x 8' Cotton
_________ x $20.00
$____________
Flying and certification
___________ x $4.05 (per flag)
$____________
Shipping and Handling
___________ x $4.00 (per flag)
$____________
   
 Grand Total
$_____________

Request must be received two weeks prior to date flag is to be flown.

Please allow six to eight weeks for delivery after flag is flown.