Appendix L WIC Clinic - Change of Status Form

Attachment 3: WIC Clinic - Change of Status Form

Please complete this form every time there is a change to clinic information. This form should be submitted at least 10 days prior to the change taking effect. This form is for WIC program purposes only and does not replace the appropriate Cornerstone forms.

Today's Date: Date Change Will Occur:
Current Information Change Information to
Agency: New Agency (if applicable):
Clinic or Satellite Site Name: Clinic or Satellite Site Name:
Site Supervisor or Contact:"sans-serif"; color:black'>Site Supervisor or Contact: Site Supervisor or Contact:
Voice Phone Number: Voice Phone Number:
Fax Phone Number: Fax Phone Number:
Site Address: Site Address:
Bank Draft (FI) Delivery Address: (If different from Site Address above) Bank Draft (FI) Delivery Address: (If different from Site Address above)
Emergency Formula Delivery Address: (If different from Site Address above) Emergency Formula Delivery Address: (If different from Site Address above)
Regional Representative Signature: Regional Representative Signature

Mail form to: DHS/Bureau of Family Nutrition

Attn: Linda Butler/WIC

535 W. Jefferson St., 3rd Fl.

Springfield, IL 62702-5058

Attachment 5: WIC Clinic - Change of Status Form

Please complete this form every time there is a change to clinic information. This form should be submitted at least 10 days prior to the change taking effect. This form is for WIC program purposes only and does not replace Cornerstone Change of Status forms.

Today's Date: Date Change Will Occur:
Current Information Change Information to
Agency: New Agency (if applicable):
Clinic or Satellite Site Name: Clinic or Satellite Site Name:
Site Supervisor or Contact: Site Supervisor or Contact:
Voice Phone Number: Voice Phone Number:
Fax Phone Number: Fax Phone Number:
Site Address: Site Address:
Bank Draft (FI) Delivery Address: (If different from Site Address above) Bank Draft (FI) Delivery Address: (If different from Site Address above)
Emergency Formula Delivery Address: (If different from Site Address above) Emergency Formula Delivery Address: (If different from Site Address above)
Regional Representative Signature: Regional Representative Signature

Mail form to: DHS/Bureau of Family Nutrition

Attn: Linda Butler/WIC

535 W. Jefferson St., 3rd Fl.

Springfield, IL 62702-5058