WIC Nutrition Program
Tel. (207) 287-3991 or (800) 437-9300
WIC Vendor Application
Fax: 207-287-3993
*= Required Field Incomplete or unsigned application may delay authorization. *= Required Field
*
TYPE OF REQUEST
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st
New WIC Application
Renewal WIC Application, Complete by October 1
Vendor no. ___ ___ ___ ___
*
OWNERSHIP TYPE (MARK ONE)
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□
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Corporate
Sole Proprietorship
Partnership
Government
Other:
*
TYPE OF AUTHORIZATION
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Retail Food Vendor ‐ licensed by the Maine Department of Agriculture(AG) that has no pharmacy on its premises
◊
◊
Franchise
Independent
Convenience Store
Grocery Store
Name
□
Retail Food Vendor with Pharmacy –licensed by AG & Commission of Pharmacies under the same ownership on the same premises
Franchise
Independent
Name
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Pharmacy Vendor‐ registered through the Maine Commission of Pharmacies that is not operating as a food vendor
Franchise
Independent
Name
*
BUSINESS INFORMATION
*Business Name:
*Physical Location Address:
*City:
*State:
*ZIP Code:
Business Mailing Address (if different):
*City:
*State:
*ZIP Code:
( ) ‐
( ) ‐
*Phone:
Fax:
E‐mail:
Store Contact Name:
Job Title:
*Owner’s Name 1:
WIC stores Owned
Non‐WIC stores Owned
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Mailing Address:
same
( ) ‐
( ) ‐
Phone:
Cell:
E‐mail:
*Owner’s Name 2:
WIC stores Owned
Non‐WIC stores Owned
□
Mailing Address:
same
( ) ‐
( ) ‐
Phone:
Cell:
E‐mail:
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*Does the applicant own the real estate where the store is located?
Yes
No
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*Is your store in a Permanent Fixed Location?
Yes
No
*SSN:/ Federal ID:
□
□
Do Cash registers flag WIC items?
Yes
No
*Number of Cash Registers
Number of Cashiers:
For questions contact us at:
Ph.: 1-800-437-9300 or E-mail:
WIC.Maine@Maine.gov
For Resources visit:
Revised: 6/16/2015
O:\Vendor Relations\Vendor Training\2015 Group Training\2015
Region 1\Vendor Application FY2015.docx