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<br />*This checklist is not part of the NACo contract, however, please return it witli your signed contract <br />*Incomplete or incorrect cl:ecklists will delay implementation of the program* <br />NACo Prescription Drug Program checklist <br />County Name/State: 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 <br />E-mail (We must have your a-mail address!) <br />Fax <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 CONTRACT IS RETURNED TO NACo. Please plan your county's <br />roll out of the program accordingly. <br />3. Please choose a design for the discount cards: (YOUMUST CIRCLE ONE) <br />a. "County Name" or "County NameRx" <br />b. Logo/seal on cards <br />a. Be sure to a-mail a black and white logo/seal to agoldscl:midt@naco.org <br />or elandsman@naco.org in a jpg or.tiffformat ' <br />b. Put "(COZIIVTYNAME) LOGO" in tl:e subject line ofyour 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%ofyour 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 cards/posters in Spanish? How many? <br />5. Please provide a street address for delivery of cards. Cards 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 card? <br />********************************************************************************** <br />This section for NACo use only <br />Copy of signed contract sent to Cazemazk7 <br />Signed contract back from CazemazkT <br />Proofs approved? <br />Notes: <br />NedonatAssoeistionoi.Criuniies <br />~~~ <br />