EmailMe Form - NLC Prescription Discount Card Order Form

NLC Prescription Discount Card Order Form

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.

City Name: *

State: *

Shipping Address

Address Line 1: *

Address Line 2:

City, State: *

Zip Code: *

Primary Contact

Contact Name: *

First Last

Contact Title: *

Phone: *

### - ### - ####

Email: *

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.

How many cards printed? *

10% of your population is a good start in suggesting print quantities.

Materials in Spanish required: *

Yes

No

Are you a new city joining the program for the first time? *

Yes

No

Please provide new posters and card holders. *

Yes

No thank you

(posters and card holders are not customized with city name or logo)

Request separate Bill Stuffers to put in resident bills. *

Yes

No thank you

How many Bill Stuffers printed?

Bill Stuffer shipment needs to arrive to the above address by this date:

Do the Bill Stuffers need to arrive to a different address than the above?

Yes

No

List address here: