Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the...

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Louisiana WIC Vendor Initial Application Resources and Checklist

Vendor Name: Application Date:

Instructions: Use the resources below to assist you in completing the Louisiana WIC Vendor Application. Incomplete Vendor Applications and/or Vendor Applications submitted without all required documentation will not be accepted. If you have questions, contact us at (504) 568-8229 or lawicvendorapp@la.gov.

SECTION I – LA WIC Vendor Application Information and Resources

For assistance completing the Louisiana WIC Vendor Application, please visit the Louisiana WIC Vendor website.

• LA WIC Vendor Application• LA WIC Vendor Agreement• LA WIC Vendor Guide• LA WIC Approved Infant Formula Provider List• LA WIC Statewide Average Prices• LA WIC Food Sales Facts Sheet• Grocer’s Price Report Sheet (WIC-3)• Signature Authority Letters

o LA WIC Signature Authority Letter (for use by LLCs, Limited Liability Partnership, Partnership, SoleProprietorship)

o LA WIC Written Resolution of the Board of Directors (for use by Corporations)

SECTION II – LA WIC Vendor Application Checklist All documents listed below must be submitted with your application.

☐ Completed, signed, and notarized Vendor Application (version dated 10/2020)☐ Signed, initialed, and dated Vendor Agreement (version dated 10/2020)

☐ The same person signed both the Vendor Application and the Vendor Agreement☐ The person signing the Application and Agreement has signature authority OR the appropriate signature

authority document (listed above) is included with the application packet.☐ Copy of valid Louisiana Grocery Retail Permit labeled “Permanent Grocery/Market”. See example.☐ Copy of SNAP authorization. See example.☐ Completed, signed, and dated WIC-3 (version dated 10/2020)☐ Copy of Photo ID of owners, partners, or corporate officers☐ Copy of parish sales tax forms from the previous quarter

Complete application packets must be mailed to: LDH/OPH/Bureau of Nutrition Services

Vendor Operations Unit P.O. Box 60630

New Orleans, LA 70160

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