NOTE: In signing for this equipment it is understood that you are responsible for its return to Support Services. If the flags are not returned, or returned
damaged your office will be financially responsible. Please be sure to receive a receipt when you return this equipment.
SECTION 3: REQUEST PROCESSING
Authorizing Official (Last, First, MI) Date Must be Returned by (mm-dd-yyyy)
SECTION 4: CLOSE-OUT
Returned to (Last, First, MI) Date Returned (mm-dd-yyyy)
Items Returned.
DS-4192
04-2015
U.S. Department of State
FLAG LOAN REQUEST
Name (Last, First, MI) Request Date (mm-dd-yyyy)
Requesting Agency (If Other Than Department of State) Room Building
Office Phone Mobile Phone
SECTION 1: REQUESTER'S INFORMATION
SECTION 2: REQUEST INFORMATION
Flags
Number of Bases Number of Spires Number of Eagles Number of Poles
Purpose
Return Date (mm-dd-yyyy)
Event Location
Signature
Date (mm-dd-yyyy)
Signature
Date (mm-dd-yyyy)
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signature
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click to sign
signature
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