Vendor Request for WIC Application Packet

Please provide the following information:

Contact Information

Store Name:

Contact:

Phone Number: (format xxx-xxx-xxx)

Address Information

Store Mailing Address - Line 1:

Address - Line 2:

City:

Zip Code:

 

 

Address to Mail Application Packet if Different from Above

Mailing Address - Line 1:

Mailing Address - Line 2:

City:

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 sarah.mallberg@state.mn.us or 651-201-4430.