Retail Vendor Application Amendment Wisconsin Women, Infants And Children (Wic) Program Page 2

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F-40108 (Rev. 05/2014)

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SECTION 4: CORPORATE AGENT OR OFFICER(S) Refer to the Vendor Profile enclosed (or call 608-266-6912 to request a copy)

for current WIC ownership information and update below. If more than 4 members/officers updates, submit information on a separate.

New Corporate Agent

New Corporate Officer(s)

Corporate Agent Name (First, Middle Initial, Last)

Telephone (if different from above)

(

)

Full Name and Position Held (e.g., Name, President)

Check one

Social Security No.

Date of Birth

% of Ownership

Effective Date

 New

 Inactive

Full Name and Position Held (e.g., Name, President)

Check one

 New

 Inactive

Full Name and Position Held (e.g., Name, President)

Check one

 New

 Inactive

Full Name and Position Held (e.g., Name, President)

Check one

 New

 Inactive

SECTION 5: MANAGER(S) Refer to the Vendor Profile enclosed (or call 608-266-6912 to request a copy) for current WIC manager

information and update below. If more than 4 manager updates, submit information on a separate page.

Manager Name (First, Middle Initial, Last)

Check one

Social Security Number

Date of Birth

Effective Date

 New

 Inactive

Manager Name (First, Middle Initial, Last)

Check one

Social Security Number

Date of Birth

Effective Date

 New

 Inactive

Manager Name (First, Middle, Initial, Last)

Check one

Social Security Number

Date of Birth

Effective Date

 New

 Inactive

Manager Name (First, Middle, Initial, Last)

Check one

Social Security Number

Date of Birth

Effective Date

 New

 Inactive

SECTION 6: BUSINESS CONTACT INFORMATION

Contact Person’s Title

Contact Person’s E-mail Address

Person WIC Should Contact

Work Telephone Number

Cell Telephone Number

FAX Number

(

)

(

)

(

)

SECTION 7: CERTIFICATION

1. I certify that the information submitted on the form is accurate and complete. I affirm that I have authority to contract for the business. I understand

that the terms and conditions agreed to in the original agreement remain unchanged.

Full Name and Title of Individual Completing this Form (Type or Print):

Last Name

First Name

Middle Initial

Title

SIGNATURE – Individual Completing this Form

Date Signed

2. If the individual completing this form is not an owner, corporate officer, or other individual authorized to sign on behalf of the vendor, then the owner,

manager or other individual authorized to sign on behalf of the vendor must sign below.

Full Name and Title of Owner, Corporate Officer or Other Authorized Individual (Type or Print):

Last Name

First Name

Middle Initial

Title

SIGNATURE – Corporate Officer or Other Authorized Individual

Date Signed

Clear / Reset Form