Free Wisconsin WIC Program Retail Vendor Initial Authorization Application, DPH 40034 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 40034A (08/01)

STATE OF WISCONSIN

INSTRUCTIONS FOR COMPLETING RETAIL VENDOR APPLICATION
INFORMATION MUST BE PRINTED CLEARLY OR TYPED. All information requested in this application must be provided or it will be considered "incomplete" and returned to the applicant unprocessed. The submission of the Retail Vendor Application does not guarantee that the applicant will be authorized. Applicants must meet specific eligibility criteria. SECTION 1: STORE NAME AND ADDRESS 1A. Legal Name of Store if different than the name the store is doing business as. 1B. Operating name of store/name the store is doing business, for example the name on store signs. 1C. Telephone number of store, include area code. 1D. ­ 1H. Physical location of the store. 1I to 1L Mailing Address where WIC information will be sent, only if different than store address. SECTION 2: STORE INFORMATION 2A. Place a "4" in each box that describes the type of store. 2B. Place a "4" the box that describes the size of the store. 2C. Indicate the number of cash registers used for customer check-out. 2D. Record the most recent annual gross sales of all food and annual liquor sales. 2E. Indicate the hours the store is open to the public each day. If open 24 hours every day, check last box. 2F ­ 2G Record the name of the bank and account number where WIC drafts will be deposited. 2H - ABA Transit Routing Number ­ 9-digit number is printed behind the ":" on the lower left corner of your check 2I. ­ 2M. Telephone number and address of bank where WIC drafts will be deposited. SECTION 3: TAX INFORMATION 3A. Wisconsin Seller's Permit number issued by the Department of Revenue. 3B. Federal Tax Identification Number (FEIN). If there are no paid employees, list the owner's Social Security Number. SECTION 4: LOCATION PURCHASE INFORMATION 4A. Name of the store prior to new ownership. 4B. Indicate the month, day and year the store was purchased by the present owner(s). 4C. For newly-build stores or stores opening in a vacant building, enter the date the store opened(s) to the public. 4D. If the building in which the store is located is rented, record the full legal name and full address of the owner of the building. 4E. If the business is leased (not owned by the applicant), record the legal name and full address of the lessor/owner of the business. Provide a copy of the lease agreement. 4F. Place a "4" in the boxes that describe applicant's relationship to the previous owner. SECTION 5: OWNERSHIP INFORMATION 5. Place a "4" in box that best describes the ownership of the store. 5A. Record the full name, full address and WIC Vendor Number (if authorized) of all stores owned by the applicant located in Wisconsin. 5B. ­ 5E. Provide information requested in the section that applies to the type of ownership of the store. Only one section should be completed. Record the full legal name, address, date of birth and Social Security Number for each individual. 5F. For corporations with stockholders, provide the full legal name, address, Social Security Number and date of birth of each individual stockholder owning 25% or more of the shares of the corporation and the percentage of shares owned by each individual. If no stockholders own 25% or more shares place a "4" in the box. SECTION 6: MANAGEMENT 6. Record the full legal name, Social Security Number and date of birth of all managers for the applicant store. SECTION 7: WIC, FOOD STAMP PROGRAM AND OTHER LICENSE 7A. Answer "Yes" or "No." If yes, provide the information requested in this section regarding each owner's, corporate officer's, representative's and manager's or other individual's, who directly or indirectly participates in the operation of the store, history with the WIC Program in Wisconsin or any other state. 7B. Record the 7-digit Food Stamp Authorization number, if authorized, or check appropriate box if not authorized or if currently applying for food stamp authorization. 7C. Answer "Yes" or "No." If yes, provide the information as requested in this section regarding the corporate entity and each owner's, corporate officer's, representative's, manager's or other individual's, who directly or indirectly participates in the operation of the store, history with the Food Stamp Program in Wisconsin or any other state. 7D. Answer "Yes" or "No." If yes, include information regarding the corporate entity and each owner's, corporate officer's, representative's and manager's denial, withdrawal, suspension, revocation or fines incurred for violations of any business or occupational license or permit violations. SECTION 8: CRIMINAL CONVICTIONS 8. Answer "Yes" or "No." If yes, provide the information requested for the corporate entity and individuals listed in 1. through 7. who are now charged with or have had a criminal conviction. SIGNATURE Print/type the name and title of the person completing the application, the signature of that person and date signed. SECTION 9: AFFIDAVIT OF APPLICANT The Affidavit of Applicant must be completed by the owner, partner or corporate officer or other individual who has authorization to sign on behalf of the owner and signed before a notary public. Print or type the full legal name and title and sign and date the form before a notary public.

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40034 (08/01)

STATE OF WISCONSIN s. 253.06 (3) Wis. Stats. Chapter HFS 149 Wis. Admin. Code (608) 266-6912

WISCONSIN WIC PROGRAM RETAIL VENDOR INITIAL AUTHORIZATION APPLICATION
Read guidelines before completing this application. Completion of this form is required for authorization as a WIC vendor pursuant to s. 253.06(3) Wis. Stats. and Administrative Code HFS Chapter 149. The submission of this application does not guarantee WIC vendor authorization. Stores must meet criteria described in HFS 149. The authority for requesting and using personally identifiable information including your Social Security number is s. 253.06(3), Wis. Stats. Disclosure of your Social Security number is voluntary. Failure to complete the form may delay processing the application. Information including the Social Security number will be used to investigate eligibility or continuing eligibility for WIC authorization, and may be disclosed to federal, state and local law enforcement agencies, and federal and state tax authorities. FOR WIC OFFICE USE ONLY VENDOR NUMBER PROJECT NUMBER

SECTION 1 - STORE NAME AND ADDRESS
1A. Legal Name of Store 1B. Name Under Which Store is Doing Business (e.g., name on store signs) 1C. Telephone Number of Store ( ) 1E. P.O. Box 1F. City 1D. Store Street Address 1G. Zip Code 1J. P.O. Box 1H. County 1K. City 1L. Zip Code

1I. Mailing Address (If different than store address)

SECTION 2 - STORE INFORMATION Note Item 2D: In cases of changed ownership list the previous owner's sales if known. If previous owner's sales
are unknown, the store is newly built or opening in a vacant building, record an estimate of sales and indicate "EST" after the figure. 2A. Store Type (Check 2B. Store Size 2D. Sales Volume applicable) Under 4,000 square feet Most recent annual GROSS VOLUME of Sales $____________ Grocery 4,001 to 10,000 square feet (Total all food & non-food sales) Over 10,000 square feet Pharmacy Most recent annual LIQUOR sales $____________ 2C. Number of Cash Registers 2E. Daily Store Hours (If store is not open 24 hours/day/everyday indicate store hours below. Check last box if open 24 hours/day/everyday.) Monday _____ AM to _____ PM Friday _____ AM to _____ PM Tuesday ______ AM to ______ PM Saturday ______ AM to ______ PM 2G. Bank Account No. Wednesday _____ AM to _____ PM Sunday _____ AM to _____ PM Thursday _____ AM to _____ PM 24 hours/day/everyday 2I. Telephone Number ( ) 2L. State

2F. Bank Name Where WIC Drafts Will Be Deposited

2H. Bank's ABA Transit Routing No.

2J. Street

2K. City

2M. Zip Code

SECTION 3 - TAX INFORMATION These numbers must have been issued before a store may be authorized with the WIC Program.
3A. Wisconsin Seller's Permit Number (Wisconsin Sales Tax) Enter Six Digit Number 3B. Federal Tax Identification (F.E.I.N.) Enter Nine Digit Number

-

SECTION 4 ­ LOCATION PURCHASE INFORMATION
4A. Prior Name of Store 4B. Date of Change of Ownership: Enclose a copy of the legal proof of purchase (e.g., bill of sale, deed, lease agreement). If this is a new store, go to 4C. 4C. Stores Newly Built or Opening in a Vacant Building: Enclose a copy of ownership documentation (e.g. business agreement, lease, deed, franchise agreement). Date store officially opened(s) must be provided. Month Date Year

Month Date Year 4D. If the BUILDING in which the store is located is rented, provide the following information: Full Name of Lessor:

Address

City

State

Zip Code

4E. If the BUSINESS is leased, provide the following information and a copy of the lease: Full Name of Lessor Address City State Zip Code

DPH 40034 (08/01) Page 2 4F. Relationship of current owner(s) to previous store owner(s) (Check all that apply). If there is more than one new owner, indicate the relationship of each owner to the prior owner(s) on a separate sheet of paper. I was a partner I was an employee at the store I was a shareholder/stockholder I was a corporate officer I was a manager I am an immediate/extended family member. Please specify:___________________________________ Other (briefly describe):_________________________________________________________________ None

SECTION 5 ­ OWNERSHIP INFORMATION (Check box that best describes the ownership of your store.)
Sole Ownership Partnership Privately Owned Corporation Publicly Owned Corporation Limited Liability Company Limited Liability Partnership Cooperative Government Owned

5A. Other Stores in Wisconsin Currently Owned by Applicant (if additional space is needed, attach a separate sheet) Store Name Street Address City WIC Vendor Number Zip Code

5B. Sole Ownership (Complete if Sole Owner.) Sole Owner Name (First, Middle Initial, Last) Home Address City State Zip Code Home Telephone Number ( ) Social Security Number Date of Birth (Month/Day/Year)

5C. Government Owned (List Agent, Officer or Director. If more space is needed, attach a separate sheet with the information requested below.) Agent, Officer or Director Name (First, Middle Initial, Last Name) Social Security Number Date of Birth (Month/Day/Year)

Agent, Officer or Director Name (First, Middle Initial, Last Name)

Social Security Number

Date of Birth (Month/Day/Year)

5D. Partnership Or Limited Liability Partnership (LLP) (Complete if Partnership or LLP. If more than two partners, attach a separate sheet.) 1. Partner Name (First, Middle Initial, Last) Social Security Number Date of Birth (Month/Day/Year)

Home Address City 2. Partner Name (First, Middle Initial, Last) State Zip Code Home Telephone Number ( ) Date of Birth (Month/Day/Year)

Social Security Number

Home Address City State Zip Code Home Telephone Number ( )

5E. Corporation (Privately or Publicly Owned), Cooperative Or Limited Liability Company (LLC) (Complete for Corporation, Cooperative or LLC.) Corporation / Cooperative / LLC Name Mailing Address Agent Name (First, Middle Initial, Last) President or LLC Member Name (First, Middle Initial, Last) Vice President or LLC Member Name (First, Middle Initial, Last) Secretary or LLC Member Name (First, Middle Initial, Last) Treasurer or LLC Member Name (First, Middle Initial, Last) City Telephone (If different from above) ( ) Social Security Number Social Security Number Social Security Number Social Security Number Date of Birth (Month/Day/Year) Date of Birth (Month/Day/Year) Date of Birth (Month/Day/Year) Date of Birth (Month/Day/Year) State Telephone Number ( ) Zip Code

DPH 40034 (08/01) 5F. Corporation with Stockholders (Complete for Corporation with stockholders.) Name(s) of stockholder(s) owning 25% or more of the shares of the corporation Full Name and Mailing Address % of Shares Owned Check box if no stockholders own 25% or more shares Social Security Number

Page 3

Date of Birth (Month/Day/Year)

SECTION 6 MANAGEMENT (If more than three managers attach a separate sheet, with the information requested below.)
6A. Manager Name (First, Middle Initial, Last) Social Security Number Date of Birth (Month/Day/Year)

6B Manager Name (First, Middle Initial, Last)

Social Security Number

Date of Birth (Month/Day/Year)

6C. Manager Name (First, Middle Initial, Last)

Social Security Number

Date of Birth (Month/Day/Year)

SECTION 7 - WIC, FOOD STAMP PROGRAM AND OTHER LICENSE
7A. Has any owner(s), corporate officer(s), representative, manager(s) or other individual who directly or indirectly participates in the operation of the store ever been denied participation, for reasons other than a failed initial authorization site visit, suspended, terminated, disqualified or cited for noncompliance by the Wisconsin WIC Program or the WIC Program in any other state within the past six years or ever been permanently disqualified? Yes No

If YES, provide the following information for each action on a SEPARATE SHEET OF PAPER and attach to this application form: 1. Date of each action 2. Action taken and reason for each action 3. Name of each store for which each action was taken 4. Full address of each store for which each action was taken 5. Full name, address and title of each owner, manager, corporate officer or other individual involved in each action Include any past or current (pending) action, even if the individuals in question were employed or connected with a different store at the time of the event, or are now employed or affiliated with a different store. For example, include the situation in which the store's current owner(s)/manager(s) operate/manage or operated/managed another store at the time it was removed from or sanctioned by the WIC Program in Wisconsin or any other state. 7B. Food Stamp Authorization Number Not Authorized Authorization Applied For

7C. Has the corporate entity, any owner, any corporate officer, representative, manager, or other individual who directly or indirectly participates in the operation of the store ever been denied participation, cited for non-compliance, involuntarily withdrawn, been disqualified, or fined by the Food Stamp Program, in Wisconsin or any other state within the past six years or ever been permanently disqualified? Yes No

If YES, provide the following information for each action on a SEPARATE SHEET OF PAPER and attach to this application form: 1. Date of each action 2. Action taken and Reason for each action 3. Name of each store for which each action was taken 4. Full address of each store for which each action was taken 5. Full name and title of each owner, manager, corporate officer or other individual involved in each action Include any past or current (pending) action, even if the individuals in question were employed or connected with a different store at the time of the event, or are now connected with a different store. For example, include the situation in which the store's current owner(s)/manager(s) operate/manage or operated/managed another store at the time it was removed from or sanctioned by the Food Stamp Program in Wisconsin or any other state. 7D. Has the corporate entity, any owner, any corporate officer or any manager ever had a business, health, occupational license or permit withdrawn, suspended or revoked or been cited for non-compliance or fined for violations within the past six years? Yes No If Yes, attach an explanation for each action, listing the type of license, the reason for and date of denial, fine, suspension, revocation, withdrawal or disqualification for each individual involved in the action.

DPH 40034 (08/01)

Page 4

SECTION 8 ­ CRIMINAL CONVICTIONS
Are any of the following now charged with, or have they ever been convicted of or forfeited collateral for any felony or fraud or misrepresentation in any connection? 1. The corporate entity 2. Any owners 3. Any corporate officers 4. Any partners Yes No 5. Any managers 6. Any stockholders who have a substantial role in the operation of the store 7. Any immediate family members

If YES, attach a written explanation for each action, giving the name of each individual charged or convicted and each individual's relationship to any owner, partner, or corporate entity. Include his/her current or past position in the store or corporation; the court and court docket number, the crime(s) and date(s) committed, the penalty and time served, and any other relevant information.

Individual Completing This Application Must Provide the Following: Type / Print Name

Type/Print Title

SIGNATURE ­ Individual Completing This Application

Date Signed

SECTION 9 - AFFIDAVIT OF APPLICANT (Must be completed by the storeowner, partner or corporate officer or other individual who has authorization
to sign on behalf of the vendor.) Full Legal Name of Applicant Completing This Affidavit (Print or Type) Title

I CERTIFY THAT 1. All information submitted on this form is accurate and complete. 2. I have read and understand HFS 149, Wis. Admin. Code and the Wisconsin WIC Vendor Application Guidelines. 3. I understand that this application does not guarantee selection and authorization to participate in the Wisconsin WIC Program. 4. I understand that I may not accept drafts until authorized by the Wisconsin WIC Program. 5. I have authority to contract for the business. 6. I am applying for authorization to take part in the Wisconsin Department of Health and Family Services' WIC Program. If my application is approved by the WIC Program, I agree to abide by applicable WIC Program rules and regulations, including but not limited to HFS 149, Wis. Admin. Code, policies and procedures as stated in the application form, the contract agreement, the WIC Vendor Manual, federal regulations, and other applicable rules, statutes, and regulations and further agree to comply with amendments or updates. 7. I understand that the WIC contract must be terminated if a change of ownership occurs and agree to notify the Wisconsin WIC Program of a change of ownership. 8. I understand that neither the State or local agency nor the vendor has the obligation to renew this vendor contract. 9. I understand that either the State agency or the vendor may terminate this contract for cause after providing 15 days advance written notice. 10. I agree that my business, including all employees, will comply with Program regulations and guidelines. 11. I understand that the Wisconsin WIC Office may revoke my authorization to participate if there is noncompliance committed by myself, by any of the business' employees or representatives. 12. I understand that no conflict of interest shall exist between my business and any WIC agency. I, the above-named applicant, state that I am the person referred to in this application as the owner, partner, or corporate officer of the store indicated on the attached Wisconsin WIC Program Retail Vendor Application or that I have authorization to sign on behalf of the vendor, and that all the statements herein contained are each and all true in every respect. I understand that false statements made in connection with this application may be grounds for denial of the application or termination of the location as an authorized WIC vendor.

SIGNATURE ­ Applicant

Date Signed

Subscribed and sworn to before me this _____ day of ______________________________________, 20______.

___________________________________________________________________ Notary Public ___________________________________________________________________ State My Commission Expires ____________________________________________

SEAL

NOTE: Unless personally known to the notary public, identification provided to the notary must include two forms of identification. One must be a Driver's License, Passport, or Wisconsin State Identification.