Flags For Fallen Military Election Form In an effort to allow Flags For Fallen Military (FFM) to document your hero’s information, please provide your consent by checking the boxes below. Please email, mail or fax this completed document to dlarson@flagsforfallenmilitary.org or 888-616-3420 (fax number) or mail to the address listed below. By checking the box (es) below, you agree to allow FFM to list your hero on our website, twitter or facebook accounts. Your decision of whether or not to participate will not impact whether or not you receive a flag; it is a formality to respect the privacy of all of our fallen and the families we serve. We agree to have our hero listed on the following social media sites: □ FFM Website □ FFM Twitter accounts □ FFM Facebook sites Heroes first and last name: ______________________________________________ Branch and rank: _______________________________________________________ Date of death: _________________________________________________________ Age: __________________________________________________________________ City: __________________________________________________________________ State: _________________________________________________________________ Phone #: _______________________________________________________________ Email address: __________________________________________________________ Flag pole recipient signature:______________________________________________ Thank you and please call or e-mail me with any additional questions. Sincerely,

David & Lisa Larson Founders, Executive Director 612-309-8456 PLEASE "LIKE" US ON FACEBOOK!