Order form to request more information and for cities in the NLC Prescription Discount Program to request the new version of customized city discount cards
Street Address Line 2:
Pirimay Contact Name:
Primary Contact Title:
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:
Please provide new posters and card holders as well (posters and card holders are not customized with city name or logo)
No thank you