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*This checklist is etat part of the NACo conlraM, however, please return it with your signed contract. <br /> *Incomplete or incorrect checklists will delay implementation ojthe 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 (wJ 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 /> 8-]0 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 Name}3x" <br /> b. Logo/seal on cards <br /> a. Be sure to a-mail a 6[ack and white logo/seal to agoldschmidt <br /> a(~jtaca.org <br /> or elandsman~r~jtaco. org in a .jpg or ,tiff <br /> format <br /> b. Put "(COUNTYNAME) LOGO" in the 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 aze 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 /> s**s~rer+*«?*~r*•**r*sr:s**#*rrer*•s<rr*******st*eers***#*sarss*+*s?wss**~r?r¦*~*:**~ <br /> This section forNACo use only <br /> Copy of signed contract sent to Caremark? <br /> Signed contract back from Caremark? <br /> Proofs approved? <br /> f - ~ NeliaidAsfaciaionof C°unlias <br /> <br /> Notes: <br /> <br />