WIC Vendor+ Certification Application

1. Store details *This question is required.

	Store name
	Vendor number (7-digit)
	Store address (street, city, zip)
	Store phone number
	Store email (best email to reach you at)

2. Personal details (of person applying on behalf of the store) *This question is required.

	First name
	Family name
	Job position/description
	How long have you been a WIC Vendor?

3. Are you available to participate in four (4) pre-scheduled in-store visits over the period of one (1) month to discuss goals, receive personalized WIC assistance and training and make improvements in your store? *This question is required.

4. What key challenges would you like the WIC program to address to support your business needs? *This question is required.

Please enter an 'other' value for this selection. * This question is required.

5. Have you attended any previous WIC vendor conferences, quarterly calls, regional forums or working group meetings? *This question is required.

Please enter an 'other' value for this selection. * This question is required.