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WV WIC Vendor Inquiry Form August 30, 2008 *indicates required field(s) If you are a manager or owner of a store located in the State of West Virginia and are interested in becoming authorized to accept WV WIC Customers please complete the following information: Store Name* Contact Person for Store* Please provide the mailing address of the participating location Mailing Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Email Address Phone Number* Fax Number Please provide the physical address of the participating location Street Address* City* County* Barbour Berkeley Boone Braxton Brooke Cabell Calhoun Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Jefferson Kanawha Lewis Lincoln Logan Marion Marshall Mason Mc Dowell McDowell Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas Ohio Pendelton Pendleton Pleasants Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood Wyoming unknown State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Comment or other question?
Store Name*
Contact Person for Store*
Please provide the mailing address of the participating location
Mailing Address*
City*
Email Address
Phone Number*
Fax Number
Please provide the physical address of the participating location
Street Address*
Comment or other question?
