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"Thu check!!rtv not part ojthe NACo contracS however, please retarn tY with your atgned contract" <br />"Incompkt~ or Incorrect checklists wiU dslay hnp/ementadon ojthe program* <br />NACo Prescription Drug Program checklist <br />County Name/State: Date contract returned to NACo; <br />1. Who is Ute ONE contact person in the county with whom we may communicate about this program? <br />Name and title <br />Address (w/CJty, Sate, <br />Phone <br />E-mail (We moat have your e-mail address!) <br />2. What is your county's anticipated alert-up date for the program? CURRENT START UP TIME IS <br />8-10 WEEKS FROM THE TIME THE CONTRACT IS RETURNED TO NACa Please plan your county's <br />roll out of the program accordingly, <br />3. Please choose a design for the discount cards: (YOU MUST CIRCLE ONE) <br />a. "County Name" or "County NemeRx" <br />b. Logo/soal oa cards <br />a. Bs sera to t-mall a b(ruh and white logoheol m agoldschmldt(a,)naco.org <br />or e/andaman®naco.org to a,/PS or.NJjjonnaJ <br />b. Pat "(CDUNTYNAMEJ LOGO" in the subJect dne ojyour s-matl <br />c. Other. You moat 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. Soma couatiea may need more.) <br />a. What is your county's population? <br />b. Do you need carda/poetere 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 addross (if available)? <br />Will thla program have it9 own page? (Please provide) <br />What number would county residents call to pick up a card? <br />iiiiitiiiitYiiiiiiiiill;itiiiiiitiitiii-iiiiiiiiiiiiiiiii-iiiiiiiiiiii-iiiiiiiiiiii <br />ThG rrceonfor NACo wr onfy <br />Copy of danad connect wnt to Cawmak7 <br />Sipwd oontnet back 6om Ceremadc4 <br />Prooft tpprovad7 <br />Notes: <br />NA[;o <br />