Sign Up for the Prescription Discount Card Program

If your city is interested in offering the NLC Prescription Discount Card to your residents, please fill out the requested information below and click Submit.


*Submitting this form does NOT enroll your city; a staff person from NLC will contact you to initiate the sponsorship process.
Full Name: *
Title: *
City Requesting Sponsorship *
Mailing Address: *
City, State and Zip Code: *
Phone: *
FAX:
Email Address: *