WIC Retailer Application Forms for Owner and Store

Thank you for your interest in authorization as a WIC retailer.

To be considered for authorization, each owner must submit a Request for Authorization (Owner).  A Request for Authorization (Retailer) must also be submitted for each retailer, even if the retailer has previously been authorized for WIC.

For example, a business operating a single store would submit both a Request for Authorization (Owner) form and a Request for Authorization (Retailer) form.  A business operating nine stores would submit one Request for Authorization (Owner) form and nine Request for Authorization (Retailer) forms.

Submit completed applications to:

WIC Nutrition Program
Attn:  Retailer Management Team
PO Box 47886
Olympia, WA  98504–7886

For more detailed information download the application instructions below.

Application Forms

• Owner (Business) (PDF, 33.48 KB)
• Retailer (Store) (PDF, 35.04 KB)
• Application Instructions (PDF, 35 KB)

Applications received after January 31, 2009 may not be able to be processed in time for the beginning of the April 1, 2009 contract period, so return your completed forms as soon as possible.

If you have questions, call 1-800-841-1410, ext 3620 for our Customer Service Specialist.

Documents posted in PDF format on the Department of Health Web site will be made available on request to users who are unable to download or view them. For persons with disabilities, PDF documents will be made available on request in other formats. To submit a request, contact WIC's Web Coordinator. Download the free PDF viewer here.

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call 800-795-3272 (voice) or 202-720-6382 (TTY). USDA is an equal opportunity provider and employer.

Washington WIC does not discriminate.

DOH Home | Access Washington | Privacy Notice | Disclaimer/Copyright Information

WIC Program
Washington State Department of Health
PO Box 47886
Olympia, Washington, 98504-7886

Last Update:  10/02/2009 12:32 PM
Send inquires about DOH and its programs to the Health Consumer Assistance Office.
Comments or questions regarding this web site? Send an email to the WIC Web Coordinator.