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<br />*This checklist is not part of the NACo contract, however, please return it with your signed contract <br />*Incomplete or incorrect checklists will delay implementation of the program <br />NACo Prescription Drug Program checklist <br />County NamelState: (~RA~6f ~0 4~Y IVG Date contract returned to NACo: <br />1. Who is the ONE contact person in the county with whom we may communicate about this program? <br />Name and title ~y A M «/ C'o 5'r0~~ "~/p2.c GT"rz ~ .SoC ~ ~ ~ 5~~ y r ~~ s <br />Address (w/City, State, Zip) ~ !3 . ~:ap.C O ~ ~ l <br />/-~iL~ s ,r3o~o4GK /~/ C o? ~a 78 <br />Phone Q / Cr .?y,S" o? 8'V o Fax~l/ ~ ~i 4/ `/ 3 yOS <br />E-mail (We must have your a-mail address!) 11Ga5TO.y ~ Go . on~,~ye , /-~• 4 3 <br />2. What is your county's anticipated start-up date for the program? CURRENT START UP TIME IS <br />8-10 WEEKS-FROM THE TIME THE CO~TRACT IS RETURNED TO NACo. Please plan your county's <br />rollout of the program accordingly. ~/gM4~•r~ -Zao~' <br />3. Please choose a design for the discount cards: (YOU MUST CIRCLE ONE) <br />• <br />a. "County Name" or "County Nameltx" <br />Logo/seal on cards <br />a. Be sure to a-mail a black and white logo/seal to agoldschmidt a~aco.org <br />or elandsman(~aco.org in a jpg or .tiff format <br />b. Put "(COUNTY NAME) LOGD" in the subject line of your a-mail <br />c. Other. You must contact NACo if you do not choose either a or b. <br />4. How many cards are you requesting? (We are advising 20% to 25% of your county's total population, . <br />on average. Some co~nt~,es may need more.) <br />3 v, tX~O <br />a. What is your county's population? j/ P~ocr~ <br />b. Do you need cards/posters in Spanish? How many? ~ r' 3 ~O <br />5. Please provide a street address for delivery of cazds. Cards will be sent via UPS Ground. <br />NO PO BOXES! <br />~On l/(J~ 5t' 7R yp.t/ $f~t t FT <br />v~ ~ 7~ <br />What is your county's web address (if available)? tiJ 6tJw Co , o arw s ~ c . s <br />Will this program have its own page? (Please provide) ' <br />What number would county residents call to pick up a card? g~ o?`><~ s78l~1~ <br />*~****~***************************************s************************s********** <br />This section for NACo use only <br />Copy of signed contract sent to Caremaslc? <br />Signed contract back from Caremark? <br />Proofs approved? <br />I Notes: <br />N~~~ fVlatia+ialCov+~Gas <br />~~ <br />~~~ ~+ <br />