Spreadsheet: a5940623-73ba-4f46-b113-47bdfe562539
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | INDIANA WIC PROGRAM FOOD VENDOR APPLICATION State Form 48064 (R5 / 6-13) Indiana State Department of Health | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | * This agency is requesting disclosure of Social Security Numbers (SSN) in accordance with IC 4-1-8-1; disclosure is voluntary and you will not be penalized for refusal. | Unnamed: 11
INSTRUCTIONS: |  | 1. Read Vendor Manual and Food List before completing this application. 2. Complete all items on this application and the food list.  Incomplete applications cannot be processed and will be returned.   3. For questions needing explanations, attach an additional sheet, if needed. 4. Mail the completed application and food list to Indiana WIC Program, [NAME], Indianapolis, IN 46204; or, email to [EMAIL].
Part 1.  Store information
If currently authorized, what is your WIC Identification Stamp number?
In what County does the store reside?
Store Name: |  |  |  |  |  |  | Telephone Number:
Street Address:
City: |  |  |  |  | State: |  |  |  |  | ZIP code:
Mailing address for letters, information, updates:
Street Address:
City: |  |  |  |  | State: |  |  |  |  | ZIP code:
Delivery address for WIC vendor supplies such as food lists and shelf tags:
Street Address:
City: |  |  |  |  | State: |  |  |  |  | ZIP code:
Does the store use scanners? |  |  |  |  | If Yes, do you flag WIC items in the scanner system?
Square footage of retail space under roof:
Number of cash registers used to redeem WIC checks: |  |  |  |  |  |  | Number of cashiers:
Food Stamp Program (SNAP) 7 digit permit number: |  |  |  |  |  |  |  | Date of issue (month, day, year):
Annual food sales of all foods eligible under the Supplemental Nutrition Assistance Program (SNAP) (non-taxable foods):
Annual non-food sales (taxable):
Annual total sales (Estimate all sales if in business less than one (1) year.):
Number of hours the store is open for WIC or food instrument redemption per week:
Indiana State Sales Tax number (retail Merchants Certificate 10-digit number):
Federal Tax Identification 9-digit number:
County Health Department Food Service
Permit number and expiration date: |  |  |  | Number |  |  |  | Expiration Date (month, day, year)
Store manager name: |  |  |  |  |  |  | Title:
Grocery manager name: |  |  |  |  |  |  | Title:
Cashier [NAME]: |  |  |  |  |  |  | Title:
Bookkeeper/Finance Name: |  |  |  |  |  |  | Title:
[NAME] coordinator name: |  |  |  |  |  |  | Title:
Pharmacy manager name: |  |  |  |  |  |  | Title:
Name of bank where WIC checks are/will be deposited:
Address: |  |  |  |  | City: |  |  | State: |  | ZIP code:
Bank Contact Name: |  |  |  |  |  | Telephone number:
Store e-mail address:
What kind of Internet connection do you have? |  |  |  |  |  |  |  |  | Other:
Part 2.  Supplier Information
Primary Grocery Wholesaler name:
Address: |  |  |  |  | City: |  |  | State: |  | ZIP code:
Contact Name: |  |  |  |  |  | Telephone number:
Licensed [NAME] name:
Address: |  |  |  |  | City: |  |  | State: |  |  | ZIP code:
Contact Name: |  |  |  |  | Telephone number: |  |  |  | E-mail address:
Part 3.  Ownership Information
How does this business operate (check one)?
 | Sole owner  (Complete Section A.) |  |  |  |  | Corporation  (Complete Section C.)
 | Partnership  (Complete Section B.) |  |  |  |  | Commissary (Proceed to Part 4.)
Section A.  Sole Owner
Name of business if different from store name:
Name of owner: |  |  |  |  | SSN*: |  |  | Date of Birth (month, day, year):
Home street address: |  |  |  |  |  |  |  | Home telephone / cell:
City: |  |  |  | State: |  |  | ZIP code: |  |  | E-mail:
Do you own, operate, or manage other authorized WIC stores in Indiana? |  |  |  |  |  |  |  |  | If Yes, how many?
If Yes, do any of these stores operate under a different store name?
If Yes, list vendor identification number(s), store name(s), and address(es).  (Attach additional sheets if needed.)
Vendor identification number: |  |  |  |  | Store Name:
Address: |  |  |  |  | City: |  |  | State: |  | ZIP code:
Section B.  Partnership
(If more than four (4) partners, attach a separate sheet with the additional information.)
Name of business if different from store name:
1. Name of Partner: |  |  |  |  | SSN*: |  |  | Date of Birth (month, day, year):
Home street address: |  |  |  |  |  |  |  | Home telephone / cell:
 |  | City: |  |  |  | State: |  |  | ZIP code:
 | E-mail address:
2. Name of Partner: |  |  |  |  | SSN*: |  |  | Date of Birth (month, day, year):
Home street address: |  |  |  |  |  |  |  | Home telephone / cell:
 |  | City: |  |  |  | State: |  |  | ZIP code:
 | E-mail address:
3. Name of Partner: |  |  |  |  | SSN*: |  |  | Date of Birth (month, day, year):
Home street address: |  |  |  |  |  |  |  | Home telephone / cell:
 |  | City: |  |  |  | State: |  |  | ZIP code:
 | E-mail address:
4. Name of Partner: |  |  |  |  | SSN*: |  |  | Date of Birth (month, day, year):
Home street address: |  |  |  |  |  |  |  | Home telephone / cell:
 |  | City: |  |  |  | State: |  |  | ZIP code:
 | E-mail address:
Do you own, operate, or manage other authorized WIC stores in Indiana? |  |  |  |  |  |  |  |  | If Yes, how many?
If Yes, do any of these stores operate under a different store name?
If Yes, list vendor identification number(s), store name(s), and address(es).  (Attach additional sheets if needed.)
Vendor identification number: |  |  |  |  | Store Name:
Address: |  |  |  |  | City: |  |  | State: |  | ZIP code:
Section C.  Corporation
Name of Corporation:
Corporate street address:
 |  |  | City: |  |  |  | State: |  |  | ZIP code:
Primary Contact Name: |  |  |  |  |  | Title:
 | E-mail address: |  |  |  |  |  |  | Telephone number:
Person designated to sign WIC application and [NAME]:
Name: |  |  |  |  |  | Title:
 | E-mail address: |  |  |  |  |  |  | Telephone number:
Person designated to receive any notices of WIC violations:
Name: |  |  |  |  |  | Title:
 | E-mail address: |  |  |  |  |  |  | Telephone number:
Person responsible for flagging WIC approved foods in the store scanner:
Name: |  |  |  |  |  | Title:
 | E-mail address: |  |  |  |  |  |  | Telephone number:
Person responsible for cashier training:
Name: |  |  |  |  |  | Title:
 | E-mail address: |  |  |  |  |  |  | Telephone number:
Person responsible for making available all special infant formula and medical food through the pharmacy  and for quoting prices on items not regularly stocked:
Name: |  |  |  |  |  | Title:
 | E-mail address: |  |  |  |  |  |  | Telephone number:
Do you own, operate, or manage other authorized WIC stores in Indiana under a different store name?
If Yes, list the store names:
Corporate Officers' names: |  |  | (List any additional officers on a separate sheet.)
CEO / President: |  |  |  |  |  | Vice President:
Secretary: |  |  |  |  |  | Treasurer:
Part 4.  History of Ownership
When did the owner begin doing business at this address? |  |  |  |  |  | Date (month, day, year):
(WIC cannot pre-approve stores.)
Did the owner buy or start the business you are applying for? |  |  |  |  |  |  | Buy (Answer a.-f. below) |  |  | Start (Proceed to Part 5.)
a. | From whom did the owner buy the business?
b. | Was the current owner(s) previously an owner, partner, officer, or employee of the business purchased?
 |  |  | (Explain the relationship.)
c. | What was the closing date of the sale of the business? (month, day, year)
d. | Does the previous owner have any financial interest in, or hold a mortgage on the business or the building in which the business is operating?
 |  |  | Date previous owner ceased all involvement with operation of the store (month, day, year):
e. | Do you employ or contract in any capacity with any previous owner(s) of this building or business?
 |  | (List names.)
f. | If this store location was previously owned and operated under another name, list the former name and former owner(s).
 | Former name:
 | Former owner(s):
Part 5.  [NAME]
Have the owners, officers, or managers of this store, during the past ten (10) years, ever:
 | (Check all that apply and list each occurrence on a separate sheet explaining when, where, and why for each occurrence.)
Has the store, the store owners, officers, or managers been subject to any civil, criminal, or administrative action to include any action now pending or within the past ten (10) years in Indiana or another state, which reflects on their business practices, reputation, or integrity?
 |  | (If Yes, on an attached sheet explain the nature of the action and when.  List all occurrences.)
Does an employee of the state or local WIC agency or any member of his/her immediate family or his/her business partner have any financial interest in this store?
 |  | (If Yes, on an attached sheet explain who and the extent of the interest.)
Are any of the current store owners related (including in-laws) to any previous owners at this location?
 |  | (If Yes, on an attached sheet explain the relationship and names of the related people, and note the time period when the previous owners owned the store.)
Was the previous related owner disqualified, fined, sent a warning letter, or sent a notice of Complaint and Request for Hearing from WIC or the Food Stamp Program (SNAP)?
 |  | (If Yes, explain on an attached sheet.)
Do you expect to derive more than 50% of your store's annual food sales revenue from WIC food instruments (Checks)?
Are WIC approved foods marked with prices on or near the foods?
It is the WIC vendor's responsibility to prevent the improper return or exchange of items purchased with WIC checks by providing receipts to WIC customers, marking "WIC" on those cash register receipts and then, requiring a receipt for return of WIC items?
Does your store currently require a receipt for returns and exchanges?
If No, will your store require a receipt for returns if authorized to be a WIC vendor?
MY SIGNATURE CERTIFIES THAT:
I am authorized to sign and submit this application on behalf of the store.
All of the submitted information is accurate and nothing has been withheld.  I understand that any inaccurate or withheld information may result in rejection of this application.
I understand that the State WIC Program has the authority to approve or reject applications.
If you are submitting your application by e-mail, your typed name will be accepted as an electronic signature.
Authorized Signature |  |  |  |  |  | Title of Authorized Official
Typed/Printed Name of Above Official |  |  |  |  |  | Date Application Signed (month, day, year)
The information provided on the Indiana WIC Vendor Application is used to determine whether an applicant meets  eligibility requirements,  to collect information for statistical purposes, and to have accurate mailing and contact information.   Failure to provide the requested data will result in denial of your application.
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department.  (Not all prohibited basis will apply to all programs and/or employment activities.)  If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form.  You may also write a letter containing all of the information requested in the form.  Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [EMAIL].  Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).  USDA is an equal opportunity provider and employer.