Wic Vendor Application Form - Maine Department Of Health And Human Services

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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
 
st
 New WIC Application  
 Renewal WIC Application, Complete by October 1
   Vendor no. ___ ___ ___ ___
*
OWNERSHIP TYPE (MARK ONE)
 
Corporate 
Sole Proprietorship 
Partnership
Government
Other:   
*
TYPE OF AUTHORIZATION 
 
□ 
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 
□ 
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
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:
*Does the applicant own the real estate where the store is located?  
Yes          
No 
*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

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