List your WIC Vendor Number (x5), including all leading zeros here:
* must provide value
XXXXX
Select the type of application for your business.
* must provide value
WIC Vendor Renewal
Name of Individual Completing this Application
Please ensure contact information is correct. Alabama WIC will contact this individual for questions or concerns about the renewal application.
* must provide value
Email Address of the Individual Completing this Application
* must provide value
Is this store a Cost Plus store?
Note: Cost Plus Stores add a surcharge to their product cost at the register.
* must provide value
Yes
No
Store Location
Store Name:
Street Address:
City:
State:
County:
Zip Code:
Is the mailing address the same as the Store's Address?
* must provide value
Yes
No
Store Information: Street Number & Name
* must provide value
Store Information: State
* must provide value
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Store Information: County
* must provide value
Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County DeKalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County
Other County
* must provide value
Store Information: Zip Code
* must provide value
Mailing Address
Street Number & Name:
City: County:
If outside of Alabama, select other and enter County Name in the field provided:
State: Zip Code:
Mail Box Information: Street Number & Name
* must provide value
Mail Box Information: City
* must provide value
Mail Box Information: County
* must provide value
Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County DeKalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County Other State"
Mail Box Information: State
* must provide value
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Mail Box Information: Zip Code
* must provide value
###-###-####
###-###-####
Has any of your licensing information changed since your last application?
* must provide value
Yes
No
Federal Tax Identification Number (TIN):
* must provide value
SNAP Authorization Number:
* must provide value
Alabama Department of Public Health Food Permit Number:
* must provide value
Have there been any changes in ownership since your last application?
* must provide value
Yes
No
Select the legal structure of this business from the selection options and enter the name of the business
The name of the corporation or LLC must be included, or the Application will not be Processed.
Select the legal structure of this business from the selection options:
* must provide value
Corporation Name Individual (Sole) Proprietorship Limited Liability Company (LLC) Partnership
To confirm you are entering information in the correct space for this store renewal application, please select the number of owner information that needs to be submitted.
* must provide value
1 to 4 owners
More than 4 owners
1 to 4 owners
More than 4 owners
Vendors with more than 4 owners, please email wicvendortraining@adph.state.al.us or upload below, a digital copy of all store ownership percentages with whole numbers. How are you planning to submit this information?
How are you providing the complete list of owners and percent of ownership?
Email with information requested to wicvendortraining@adph.state.al.us
Upload the requested information below (select "Upload file")
Email with information requested to wicvendortraining@adph.state.al.us
Upload the requested information below (select "Upload file")
More than 4 Owners Upload
Vendors with four or less owners, list the name(s) of the owner(s), partner(s), or corporate officer(s) of the store named in this Alabama WIC Vendor application along with percentage of ownership below (Percentage of ownership must equal 100% ). Owner 1 Name: Title: Address: Email: City: State: Zip: Work Phone: Cell Phone: Owner 1's Percentage of Ownership: Owner 2 Name: Title: Address: Email: City: State: Zip: Work Phone: Cell Phone: Owner 2's Percentage of Ownership:
Owner 3 Name: Title: Address: Email: City: State: Zip: Work Phone: Cell Phone: Owner 3's Percentage of Ownership: Owner 4 Name: Title: Address: Email: City: State: Zip: Work Phone: Cell Phone: Owner 4's Percentage of Ownership:
Owner 1's Percent Ownership
Owner 2's Percent Ownership
Owner 3's Percent Ownership
Owner 4's Percent Ownership
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
###-###-####
###-###-####
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
###-###-####
###-###-####
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
###-###-####
###-###-####
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
###-###-####
###-###-####
Percentage of ownership must equal 100%
If this number is not 100%, please confirm the amounts entered for each owner.
View equation
Please confirm the owners and their percent of ownership provided on this form, by email to wicvendortraining@adph.state.al.us, or uploaded here are provided in whole numbers and equal exactly 100% for a complete application. Are there more than 3 additional stores in which the owner(s) have ownership or interest?
Yes
No
List other stores in which the owner(s) have ownership or interest. Notate if the stores are currently authorized to accept WIC food instruments in any state.
1.
Store Name:
WIC Vendor ID:
Location (including state):
WIC Authorized:
2. Store Name:
WIC Vendor ID:
Location (including state):
WIC Authorized:
3. Store Name:
WIC Vendor ID:
Location (including state):
WIC Authorized:
*
additional wic store 1 vendor id
additional wic store 2 vendor id
additional wic store 3 vendor id
Additional Wic Authorized Store 1 Address
Additional Wic Authorized Store 2 Address
Additional Wic Authorized Store 3 Address
Additional Store 1 WIC Authorized?
Yes
No
Additional Store 2 WIC Authorized?
Yes
No
Additional Store 3 WIC Authorized?
Yes
No
Vendors with more than 3 stores in which the owner(s) have ownership or interest, please email to wicvendortraining@adph.state.al.us or upload here, a digital listing of all stores including each store name, WIC vendor ID, location including state, and WIC authorization.
Email with information requested to wicvendortraining@adph.state.al.us
Upload the requested information below (select "Upload file")
Email with information requested to wicvendortraining@adph.state.al.us
Upload the requested information below (select "Upload file")
Upload a digital copy of all store listings including each store name, WIC vendor ID, location including state, and WIC authorization here:
Has any current owner or officer been disqualified or assessed civil money penalties from SNAP in any state?
If yes, provide the dates and state: From: To: State:
*
Has any current owner or officer been disqualified or assessed civil money penalties from SNAP in any state?
* must provide value
Yes
No
SNAP Disqualification or assessed civil money penalties start date
* must provide value
Today M-D-Y
SNAP Disqualification or assessed civil money penalties end date
* must provide value
Today M-D-Y
State of SNAP disqualification or assessed civil money penalties
* must provide value
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Has any current owner or officer been disqualified from any WIC program?
If yes, provide the dates and state: From: To: State:
*
Has any current owner or officer been disqualified from any WIC program?
* must provide value
Yes
No
wic disqualification start date
* must provide value
Today M-D-Y
wic disqualification stop date
* must provide value
Today M-D-Y
State of WIC disqualification or assessed civil money penalties
* must provide value
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
During the last six years, have you (the applicant) or any of your current owners, officers, agents, or managers been convicted of or had a civil judgment entered against them for any activity indicating a lack of business integrity?
If yes, provide their name, title, dates and state: Name: Title: From: To: State:
*
During the last six years, have you (the applicant) or any of your current owners, officers, agents, or managers been convicted of or had a civil judgment entered against them for any activity indicating a lack of business integrity?
* must provide value
Yes
No
title
* must provide value
start
* must provide value
Today M-D-Y
Today M-D-Y
State of business integrity
* must provide value
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
List the name of the person with primary on-site responsibility for daily operations:
Name:
Title:
Contact Number:
Email Address:
*
Operations Name
* must provide value
Operations Person Title
* must provide value
Operations Person Number
* must provide value
###-###-####
Operations Person Email
* must provide value
Is the primary contact person for WIC issues , different than above?
* must provide value
Yes
No
WIC Point of Contact
* must provide value
WIC Point of Contact Title
* must provide value
Provide primary contact person's name, number, and email address for WIC issues , if different than above:
Name:
Title:
Contact Number:
Email Address:
*
WIC Point of Contact Email
* must provide value
WIC Point of Contact Phone Number
* must provide value
###-###-####
Square Feet of Retail Space:
* must provide value
Number of manned cash registers:
Number of self-checkout registers: Total of cash registers:
manned
* must provide value
View equation
Do the registers have scanners?
* must provide value
Yes
No
Do the scanners identify WIC foods?
* must provide value
Yes
No
Is your Point of Sale (POS) system programmed to accept all forms of payment including eWIC, SNAP, debit, credit, and cash?
Note: To be an approved vendor, your point of sale must be programmed to accept all forms of payment.
* must provide value
Yes
No
What is the name of the POS provider (The company that maintains your system)?
Name of person who is your Point of Contact for your POS provider:
Phone number for your POS provider (including area code):
*
What is the name of the POS provider (The company that maintains your system)?
* must provide value
Name of person who is your Point of Contact for your POS provider:
* must provide value
Phone number for your POS provider (including area code):
* must provide value
###-###-####
Is your POS system eWIC certified in Alabama?
* must provide value
Yes
No
Provide source of internet connection (dial-up, DSL, cable, fiber, satellite, high speed):
* must provide value
Do you have a three-prong power outlet and analog telephone line or digit/cable internet service with a
jack within 5 feet of where the register/current POS terminal is installed?
* must provide value
Yes
No
Days and hours of store operation:
DAY OF THE WEEK
OPEN TIME
CLOSE TIME
24-HOURS
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
*
Monday Opening Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Monday Closing Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Tuesday Opening Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Tuesday Closing Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Wednesday Opening Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Wednesday Closing Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Thursday Opening Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Thursday Closing Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Friday Opening Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Friday Closing Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Saturday Opening Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Saturday Closing Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Sunday Opening Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Sunday Closing Time
* must provide value
12:00 AM 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM Closed
##:##
Formula Source:
* must provide value
Formula Source Address:
* must provide value
Formula Source city:
* must provide value
Formula Source state:
* must provide value
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Formula Source zip code:
* must provide value
Primary Wholesaler or Distributor:
* must provide value
Wholesaler or Distributor Address:
* must provide value
Wholesaler or Distributor city:
* must provide value
Wholesaler or Distributor state:
* must provide value
Alabama Florida Georgia Mississippi Tennessee ------- Alaska Arizona Arkansas California Colorado Connecticut Delaware Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Wholesaler or Distributor zip:
* must provide value
Gross Total Sales Figures
SELECT THE APPROPRIATE BOX - GIVE YEARLY (NOT MONTHLY) AMOUNT:
If giving estimated sales, multiply the monthly amount by 12. Please make sure your food sales and non-food sales equal your gross sales.
Food Sales:
$
+
Non-Food Sales:
$
=
Gross Sales:
$
*
Indicate tax year for the amount provided:
* must provide value
2020 2021 2022 2023
Year XXXX
Gross Total Sales Figures
* must provide value
Estimated - New stores without full year of actual sales.
Actual - Indicate tax year for the amount provided:
Estimated - New stores without full year of actual sales.
Actual - Indicate tax year for the amount provided:
View equation
Staple Food Sales
Staple foods do not include any prepared foods or accessory foods such as candy, condiments, spices, tea, coffee or carbonated and non-carbonated drinks. Staple foods include, but are not limited to, the following: Eggs, dairy products, bread, cereal, fresh fruits and vegetables, rice, pasta, fish, meat, and poultry.
SELECT THE APPROPRIATE BOX - GIVE YEARLY (NOT MONTHLY) AMOUNT:
If giving estimated sales, multiply the monthly amount by 12. If giving actual amounts, select the actual box AND enter the Tax Year for the amount provided.
Enter the Amount of Staple Food Sales: $
*
Estimated - New stores without full year of actual sales.
Actual - Indicate tax year for the amount provided:
Estimated - New stores without full year of actual sales.
Actual - Indicate tax year for the amount provided:
Indicate tax year for the amount provided:
* must provide value
2020 2021 2022 2023
Year XXXX
Is it expected that more than 50% of your annual revenue from the sale of food items will be derived from the redemption of WIC food instruments?
Note: The Alabama WIC Program does not approve stores that anticipate more than 50% of annual revenue from the sale of food items derived from the redemption of eWIC food instruments. If the answer to question is no, and it is determined after store approval that sales data indicates more than 50% of the store's revenue is derived from the redemption of eWIC food instruments, the vendor contract will be terminated .
* must provide value
Yes
No
Do you currently own a WIC authorized store where the WIC sales are above 50 percent of the total annual food sales?
* must provide value
Yes
No
What is the estimated percent of annual food sales for the following types of payment? Percentages must equal 100% (all numbers must be whole numbers; no decimals.)
WIC
%
SNAP (Food Stamps)
%
Cash
%
Credit/Debit Cards
%
Confirm that Total Annual Sales Percentage is 100% Here:
%
*
Confirm that Total Annual Sales Percentage is 100% Here:
View equation
Can Not Exceed 100%
Please confirm the amounts provided. The provided values must equal exactly 100% for a complete application and the amounts you have entered are greater than 100% .
Please confirm the amounts provided. The provided values must equal exactly 100% for a complete application and the amounts you have entered are less than 100% . Do you have inventory invoices available for food items purchased and currently stocked in your store?
* must provide value
Yes
No
How many months of inventory invoices are available (0-72 months)?
* must provide value
Months not Years
Yes
No
Certification and Acknowledgement This application is NOT a vendor agreement. Authorization will not be determined until all completed application materials have been received and evaluated by the Alabama WIC Program. Completion of this application does not imply or guarantee authorization to participate in the WIC Program or to process eWIC transactions. The Department will require reimbursement for any eWIC transactions processed by the Vendor prior to authorization, completion of required vendor training, and a valid vendor contract. The store must meet and maintain Alabama WIC approved foods in the quantities and varieties as specified in the "Minimum Stock Requirements" enclosed in the application packet at pre-authorization and throughout the Alabama WIC Vendor Contract period. Authorized WIC representatives will conduct a pre-authorization site visit and must be provided access to all areas of the store to verify information provided on the application and verify stocking requirements. Make available, upon request, all records pertinent to this application, including but is not limited to, records regarding sales, invoices and/or inventory as well as copies of income and sales tax related forms. Upon review of the information presented in the application and a preauthorization site visit, any applicant expected to derive more than 50 percent of their annual revenue from the sale of food items derived from WIC transactions will not be authorized to participate as an Alabama WIC Vendor. The Alabama WIC program may not authorize a vendor applicant that is currently disqualified from the SNAP program. Provide WIC approved supplemental food items at prices that are competitive with other stores of similar size in the State. These prices shall not exceed the maximum price as set by the Department. Upon authorization, a vendor representative will be required to attend a training session regarding WIC policies and procedures. The individual attending the training session will be required to subsequently train all store employees on WIC policies and procedures.
ANTI-DISCRIMINATION CLAUSE Vendor will comply with Titles VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, Title II and Title III of the Americans with Disabilities Act (ADA) of 2022 as amended by the ADA Amendment Act of 2008, and all applicable Federal and State laws, rules and regulations implementing the foregoing statutes with respect to nondiscrimination on the basis of race, color, national origin, age, sex (including gender identity and sexual orientation), or disability, as defined in the above laws and regulations. * Sub-Recipient shall not discriminate against any otherwise qualified disabled applicant for, or recipient of aid, benefits, or services or any employee or person on the basis of physical or mental disability in accordance with Section 504 of the Rehabilitation Act of 1973 or the Americans With Disabilities Act of 2022.
By signing below, I certify that all statements in this application are true and correct and understand that false information provided to the WIC Program in connection with this application for authorization will result in denial of this application. I acknowledge understanding of all the information on this page and hereby attest that I am either the Owner or a Corporate Officer , and as such have the authority to contract on behalf of the vendor identified in this application.
Only the Owner or a Corporate Officer can sign the application.
Full Name of the Owner or Corporate Officer Signing this Application
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Title of the Owner or Corporate Officer Signing this Application:
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Phone Number of the Owner or Corporate Officer Signing this Application:
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Only the Owner or a Corporate Officer can sign the application.
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This institution is an equal opportunity provider.
* The Alabama Department of Public Health makes no concessions as to the scope of the terms "sex" or "discrimination" as they appear in Title IX of the Education Amendments of 1972 and the Food and Nutrition Act or implementing regulations.
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