New Vendor Evaluation Form - Kansas Wic Program
ADVERTISEMENT
1New Vendor Evaluation
Kansas WIC Program
Vendor name: ______________________________________________________Vendor #: __________
Location Address: ______________________________________________________________________
Phone Number: _______________________________ Vendor Contact: __________________________
Doing business as:
Full Line Grocery Store
Commissary
County: ___________________
Rural
Urban (refer to Vendor Manual for county designation)
Date of Evaluation: _________________________ Completed by: _______________________________
Type of Evaluation:
New Vendor
Change of Ownership
YES
NO
1. Does the vendor plan to derive more than 50% of their gross annual income
from the Kansas WIC program?
2. Does the vendor provide foods from a stationary location?
3. Does the food sales area equal or exceed 2000 square feet?
4. Is the sales floor accessible to clients with disabilities?
If no, does the store have accommodation plans?
5. Is the vendor currently disqualified from the Kansas Food Assistance Program?
6. Is the vendor’s cash register receipt detailed enough to permit monitoring for
the sale of unauthorized WIC foods? (Attach copy of a receipt.)
7. Does the vendor have scanners that are programmable for WIC foods?
If yes, how many: __________
8. Do you see any reason to grant an exception to any of the established criteria
because of inadequate client access?
9. Does the vendor cash register system pass the Level III certification?
Comments: ______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
LA Evaluator’s Signature: ____________________________
LA recommendation based upon evaluation visit:
Satisfactory
Unsatisfactory
State Agency use only:
Projected Peer Group: _______________________________
YES
NO
The vendor meets the pricing requirements as determined by the SA.
All documentation requested from application process has been received.
This report was reviewed and will be used by the SA as an evaluation tool during a vendor’s application process.
SA Signature: __________________________________________ Date: ________________________
Rev. June 2017
VEN 02.02.00
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business