Congresswoman Rosa L. DeLauro | Representing The Third District of Connecticut

Prefix: * First Name: *

Middle Name:

Last Name: *	Suffix:

Address: *

City, State and Zip*:

Phone: *

E-mail: *

Requested Dates for flag to Be flown: *

Flag will be presented to: *

Special Occasion: *

Flag Selection:
Size	Material	Price	Quantity	Line Total
3x5	nylon	$9.00		$
3x5	cotton	$9.25		$
4x6	nylon	$13.50		$
5x8	nylon	$18.00		$
5x8	cotton	$20.00		$
Fee to fly flag over the Capitol: $4.05 (per flag)				$
Franking Fee: $3.95 (per flag) Franking fee is not applicable if you pick up the flag from Rep. Rosa L. DeLauro' Washington office.				$
Total amount to be enclosed on check				$
Please print this form and mail it along with a check for the appropriate amount to: The Honorable Rosa L. DeLauro 59 Elm Street New Haven, CT 06510 Attn: Flags Checks should be made payable to Rosa L. DeLauro Office Supply Account Allow five weeks for delivery after flag is flown. Please write the type of flag and amount of flags you are ordering in the MEMO section of the check.
* = Required

Washington, DC 2413 Rayburn HOB Washington, DC 20515 Phone: 202-225-3661 Fax: 202-225-4890	Main District Office 59 Elm Street New Haven, CT 06510 Phone: 203-562-3718 Fax: 203-772-2260 Stratford Exchange Phone: 203-378-9005	Municipal Building Room B-20 Middletown, CT 06457 Phone: 860-344-1159 1st & 3rd Wednesday (8:30 AM-5:30 PM)	Municipal Building 229 Church Street Mayor’s Conference Room, 4th Floor Naugatuck, CT 06770 Phone: 203-729-0204 2nd and 4th Tuesday (8:00 AM-5:00 PM)	Valley Regional Planning Agency 12 Main Street Conference Room Derby, CT 06418 Phone: 203-735-5005 1st & 3rd Thursday (9:00 AM-1:00 PM)