Retail Vendor Application Amendment Wisconsin Women, Infants And Children (Wic) Program
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1
2DEPARTMENT OF HEALTH AND FAMILY SERVICES
STATE OF WISCONSIN
Division of Public Health
HFS 149 Wis. Admin. Code
F-40108 (Rev. 05/2014)
(608) 266-6912
Fill & Print Only Form
RETAIL VENDOR APPLICATION AMENDMENT
WISCONSIN WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM
This form must be completed whenever a change occurs that affects the current agreement between the vendor and the State of
Wisconsin WIC Program. Examples of changes include a change in location, management or corporate officers. The completed form,
when approved by the State WIC Vendor Management, becomes an amendment to the vendor agreement between the vendor and the
State of Wisconsin WIC Program. All other conditions of the vendor agreement remain the same.
The authority for requesting and using personally identifiable information, including your Social Security number, is §253.06(3) Wis Stats.
Disclosure of your Social Security number is voluntary. Failure to complete the form may delay processing of the amendment.
Information, including the Social Security number, will be used to investigate continuing eligibility of WIC authorization, and may be
disclosed to federal, state and local law enforcement agencies, and federal and state tax authorities.
This form may not be used when there is a change of ownership of an authorized WIC vendor. When a change of ownership
occurs, the former owner must be terminated from the program and the new owner must submit a complete Retail Vendor Application.
Contact the State WIC Vendor Management for the forms.
INSTRUCTIONS: Type or print using blue or black ink. Complete the "Current Information" section, the "Certification" section, and all
sections that apply to the change. Submit the completed form to the WIC Vendor Management, P.O. Box 2659, Madison, WI 53701-2659.
SECTION 1: CURRENT INFORMATION
Name Under Which Store is Doing Business (e.g., name on store signs)
Number of Cash Registers
Vendor Stamp Number
Telephone Number of Store
Store Street Address
City
Zip Code
(
)
Check all that apply:
Change of store location
Change in Corporate officers
Change in name
Change in manager(s)
Prices remain the same or have been reduced
Pharmacy to Grocery
Employees remain the same
Individual trained in the rules and regulations of the WIC Program remains the same
Other change (briefly describe): ______________________________________________________
New SNAP / Food Share Authorization?
Yes
No
If YES, provide the new number: ______________________________________________________________________
New Wisconsin Sellers Permit (Sales Tax)?
Yes
No
If YES, provide the new number: ______________________________________________________________________
New Federal Tax Identification?
Yes
No
If YES, provide the new number: _____________________________________________________________________
SECTION 2: NAME CHANGE
New Doing Business Name and/or New Corporation, LLC, LLP, LP, etc.
Date of Name Change
SECTION 3: LOCATION CHANGE
New Store Street Address
Opening Date at New Location
Closing Date at Old Location
P.O. Box
City
Zip Code
New Telephone Number of Store (if applicable)
Number of Cash Registers
(
)
Store Size (Check one):
Under 4,000 square feet
4,001 to 10,000 square feet
Over 10,000 square feet
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