FLAG REQUEST FORM

Please print clearly the name and complete address where the flag
order should be mailed:

Name: _____________________________________________________________

Address: __________________________________________________________
                
	 __________________________________________________________
		
	 __________________________________________________________
	 
City: ____________________________ State: VI Zip Code: ____________

Home Phone: ___________________ Business Phone: ___________________


The certificate accompanying this flag should state that it was flown
(choose one):

___ In Memory of __________________________________________________

___ For ___________________________________________________________

___ To Honor the __________________________________________________

___ Anniversary of ________________________________________________

___ To Observe the _________ Birthday of __________________________

___ Other _________________________________________________________


If it is important for this flag to be flown on a particular day,
write that day here:
                     ______________________________________________

If it important for you to receive this flag by a certain date,
write that date here:
                      _____________________________________________