Retailer Supply Request Form

Virginia WIC Program
Retailer Supply Request Form

Please enter the quantity for the items desired (1-99), complete the Contact Information, and select the “Submit” button.
WIC Approved Food Brochure (FDLST-24E) – English+
WIC Approved Food Brochure (FDLST-24S) – Spanish+
Formula Flyer (FORM LST-24-ES) – English and Spanish+
eWIC Accepted Here –Door decal*
eWIC Cashier Handbook (VEN-125)+
Wholesome Informed Choices Shelf Labels (Option #3, 100 @ 1½” x 2½” )
Wholesome Informed Choices Shelf Labels (Option #4, 100 @ 1¼ ” x 1½ ”)
Retailer Incident/Complaint Form (WIC #387)+
UPC Update Request Form
2022 WIC Program Retailer Manual/Guidelines (VEN-002)
2017 Cashier Training DVD format w/training aid
2017 Cashier Training USB format w/training aid.
1-877-TELL-WIC tear-off pad (WIC-54E/S)
Comment
Contact Information
Ship to Attention of*
Order Date
MM slash DD slash YYYY
Store Name*
WIC ID*
Address*
City*
State
Zip Code*
Phone*
Email*
Alternate Email
CAPTCHA

*Additional supplies e.g. Door decals, lane signage, etc. can be ordered directly through the eWIC Processor.

Last Updated: August 28, 2024