Free Retail Vendor Application Amendment, F-40108 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health DPH 0108 (Rev 07/08)

STATE OF WISCONSIN HFS 149 Wis. Admin. Code (608) 266-6912

RETAIL VENDOR APPLICATION AMENDMENT WISCONSIN WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM This form has been renumbered and revised. Please update your link with the following: http://dhs.wisconsin.gov/forms/F4/F40108.pdf

Employees remain the same

Other change (briefly describe): ______________________________________________________

Individual trained in the rules and regulations of the WIC Program remains the same

New Food Stamp Authorization?

Yes

No

If YES, provide the new number:

New Wisconsin Sellers Permit (Sales Tax)?

Yes

No

If YES, provide the new number:

New Federal Tax Identification?

Yes

No

If YES, provide the new number: --

SECTION 2: NAME CHANGE
New Name of Store Date of Name Change

SECTION 3: LOCATION CHANGE
New Telephone Number of Store (if applicable) ( ) P.O. Box New Store Street Address

City

Zip Code

Date Moving to New Address

Date Store Will Close at Old Address

Store Size (Check one):

Under 4,000 square feet

4,001 to 10,000 square feet

Over 10,000 square feet