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<br />*Thts checklist is not part ojthe 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 Name/State: d RAW 6< <0 4•~+T y NG 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 /V A M O y ~'v SfON ~ / /Z,c CfDiz ~ ,Sp C ~ ,¢ L $~R u t G ~ S <br />Address (w/City, State, Zip) ~ !~ . I~,( ~~ ~ ~ <br />Phone 9 /g Sys a 8'ya Fax Cl/ ~ ~i SI `/ 3yOS <br />E-mail (We must have your a-mail address!) lIOc9TO.y ~° Co . o~~e , /l ~• 4 3 <br />r <br />2. What is your county's anticipated start-up date for the program? CURRENT START UP TIME IS <br />8-IO WEEKS FROM THE TIME THE CONTRACT IS RETURNED TO NACo. Please plan your county's <br />roll out of the program accordingly.. q.44 ~s y .Zao ~' <br />3. Please choose a design for the discount cards: (YOU MUST CIRCLE ONE) <br />a. "County Name" or "County Name)Zx" <br />t~ Logo/seal on cazds <br />a. Be sure to a-mail a black and white logo/seal to agoldschmidt a~aco. org <br />or elandsman a(~aco.org in a jpg or .tiff format <br />b. Put "(COUNTY NAME) LOGO" 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 count~es may need more.) <br />v, GYRO <br />a. What is your county's population? l/ P~ ~~ <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 />.300 lilJC Sf 7R t10~t/ S>•t t FT <br />6. What is your county's web address (if available)? (tJ ltJ~•l, Co . p errs ~ n c. s <br />Will this program have its own page? (Please provide) ~- ~"Ar/np~~ <br />What number would county residents call to pick up a cazd? g/ f ~S ~~~ <br />********************************************************************************** <br />This sectiox jor NACo use only <br />Copy of signed contract sent to Caremark? <br />Signed contract back from Caremark? <br />Proofs approved? <br />Notes: <br />N A~~ nw.o~,a~no~cmn~es <br />