EmailMeForm
Sign Up Form for California Cities to Participate in Prescription Discount Card Program
City Name:
*
Street Address:
*
Street Address Line 2:
City, State:
*
Zip Code:
*
Pirimay Contact Name:
*
First
Last
Primary Contact Title:
*
Phone:
*
###
-
###
-
####
Email:
*
City Web Site:
*
Number of City Residents:
*
Logo requirements for materials
A file of the city logo/seal (jpg format) is needed in order to create the customized city card if you have not provided previously.
Upload the logo file
* Must be a jpeg or jpg
City Name on the Discount Card
*
Please confirm how the city name should appear on the ID card.
Materials in Spanish required:
*
Yes
No