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<br />*This checklist is not part of the NACo contract, however, please return it with your signed c:ontrad <br />*Incomplete or incorrect checklists wiU delay implementation ojthe program* <br />NACo Prescription Drug Program checklist <br />County Name/State: <br />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 <br />Address (w/City, State, Zip) <br />Phone Fax <br />E-mail (We must have your a-mail address!) <br />2. What is your county's anticipated start-up date for the program? CURRENT START UP TIME IS <br />&10 WEEKS FROM THE TIME THE CONTRACT IS RETURNED TO NACo. Please plan your county's <br />roll out of the program accordingly. <br />Please choose a design for the discount cards: (YOUMiTST CIRCLE ONE) <br />a. "County Name" or "County NameRx" <br />b. Logo/seal on cazds <br />a. Be sure to a-mail a black and white logo/seal to agoldschmidt(a)jeaco.org <br />or elandsman~jtaco.org in a jpg or.tijjjormat <br />b. Put "(COUNTYNAME) LOGO" in the subject line ojyour 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 counties may need more.) <br />a. What is your county's population? <br />b. Do you need cazds/posters in Spanish? How many? <br />5. Please provide a street address for delivery of cazds. Cazds will be sent via UPS Ground. <br />NO PO BOXES! <br />6. What is your county's web address (if available)? <br />Will this program have its own page? (Please provide) <br />What number would county residents call to pick up a cazd? <br />********************************************************************************** <br />This section for NACo use only <br />Copy of sigied contract sent to Caremark? <br />Sigxd contract back from Caremark? <br />Proofs approved? <br />N~~~~ <br />Notes: <br />