Request WIC Vendor Application

Store Legal Name:

Store Address:

City, State, ZIP:

Submitter Name:

Submitter Email:

Person who is authorized to sign on behalf of the company (this may be the same person as above):

Authorized Signer Email:

Have you reviewed the Application Guidelines and confirmed that your store meets the Eligibility Criteria to be a WIC Authorized Vendor: Yes No

Have you reviewed the Application Process and confirmed that you have all paperwork that will be required to submit with your application: Yes No