Distribution and Reorder Form

Return Prescription Information
 
* Indicates Required Field
*
** Display and Card Pickup Address required only needed if your information is changing **
Number of cards requested
English Discount Prescription Card
Spanish Discount Prescription Card
English Poster (limited quantities)
Spanish Poster (limited quantities)
English Carholder Displays (limited quantities)
Spanish Carholder Displays (limited quantities)
Organization *
Point of Contact Name (POC) *
POC Contact Information
Street *
City *
State *
Zip Code *
Phone
(###-###-####)		 *
Email *
Display and Card Pickup Address
Street *
City *
State *
Zip Code *
Comments
 
 
* Public Distribution Site is a business or entity requesting the marketing materials to allow them to provide the prescription cards at centralized public locations. An example of a Public Distribution Site would be a specific County Office and/or Departments location, as well as the organizations that the public visits for services the business or entity provides. The point being to provide the prescription cards to high public traffic areas that can assist as many citizens as possible. Start up quantities for partners are typically 600 to 5,000 cards based upon their needs.
 
** Partner Participant is a business requesting the marketing materials to allow them to provide the prescription cards to their organization, or employees. An example of a partner could be a restaurant association requesting a specific amount to be distributed to their employees. Start up quantities for partners are typically 100 to 500 prescription cards based on their needs.