West Virginia
WIC-Approved Food Application
Please type or print in ink.
Complete ONE application for each product or variation of a product.
1. Name of Product:
____________________________________________________
2. Company Name:
____________________________________________________
Company Address:
____________________________________________________
_____________________________________________________
Phone Number:
______________________________________________________
Contact Number:
______________________________________________________
Contact Person/Title:
____________________________________________________
3. Type of packaging (cans, glass jars, paper, plastic ,
cartons, etc.) and ALL units
available in West Virginia (46 oz. canned, 12 oz.
frozen, 20 oz. box etc.):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Average/suggested retail cost per unit:
________________________________________
5. Availability throughout West Virginia
(geographic area served by suppliers):
________________________________________________________________________
6. Date product became/will become available in
West Virginia: _______________________
Please submit the following:
________ Actual package flat or label displaying the
ingredient list.
________Actual package flat or label displaying the
"Nutrition Facts" panel. ________For cereals: Nutrition composition for iron
content, expressed in mg of iron per 100 grams of dry cereal.
________For juice: Nutrition composition for vitamin C content,
expressed in mg of vitamin C per 100 ml of juice.
_______For adult cereal and juice: A color slide or
camera-ready photo of your product which could be used on our picture food
list. This photo must be regular packaging without advertisements or
special promotional offers.
If approved for inclusion on the West Virginia WIC-approved Food List, the
manufacturer agrees to notify us promptly of product changes including,
price, distribution, labeling, or packaging. Failure to do so may
result in removal from the WV WIC-approved Food List.
______________________________________
___________________________
Signature/Title of Company Representative
Date
All applications must be received April
through June of 2006 for consideration. Applications will be reviewed
by Food List Panel in Oct-Dec 2006 for the May 2007 Food List. Mail to:
Nutrition Education Coordinator
West Virginia WIC Program
350 Capitol Street, Room 519
Charleston, WV 25301-3717
__________________________________________________________________________
WIC Office Use Only
Food Category: ____________________
Date Approved: _____________________
Date Denied: _______________________
Reason: ____________________________
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