Vendor Request for WIC Application Packet

Please provide the following information:

Contact Information

Store Name:


Phone Number: (format xxx-xxx-xxx)

Address Information

Store Mailing Address - Line 1:

Address - Line 2:


Zip Code:



Address to Mail Application Packet if Different from Above

Mailing Address - Line 1:

Mailing Address - Line 2:


Zip Code


County Information


You can expect to receive your application packet within 5 business days.

If you have any difficulty using this form, please contact Sarah Mallberg at or 651-201-4430.