Form F-40108 "Retail Vendor Application Amendment Wisconsin Women, Infants and Children (Wic) Program" - Wisconsin

What Is Form F-40108?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-40108 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-40108 "Retail Vendor Application Amendment Wisconsin Women, Infants and Children (Wic) Program" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
DHS 149 Wis. Admin. Code
F-40108 (04/2017)
(608) 266-6912
RETAIL VENDOR APPLICATION AMENDMENT
WISCONSIN WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM
This form must be completed whenever a change occurs that affects the current agreement between the vendor and the State of
Wisconsin WIC Program. Examples of changes include a change in location, management or corporate officers. The completed form,
when approved by the State WIC Vendor Management, becomes an amendment to the vendor agreement between the vendor and the
State of Wisconsin WIC Program. All other conditions of the vendor agreement remain the same.
The authority for requesting and using personally identifiable information, including your Social Security number, is §253.06(3) Wis
Stats. Disclosure of your Social Security number is voluntary. Failure to complete the form may delay processing of the amendment.
Information, including the Social Security number, will be used to investigate continuing eligibility of WIC authorization, and may be
disclosed to federal, state and local law enforcement agencies, and federal and state tax authorities.
This form may not be used when there is a change of ownership of an authorized WIC vendor. When a change of ownership
occurs, the former owner must be terminated from the program and the new owner must submit a complete Retail Vendor Application.
Contact the State WIC Vendor Management for the forms or you may download the forms by going to www.dhs.wisconsin.gov/wic/.
INSTRUCTIONS: Type or print using blue or black ink. Complete the "Current Information" section, the "Certification" section, and all
sections that apply to the change. Submit the completed form to the WIC Vendor Management, P.O. Box 2659, Madison, WI 53701-
2659.
SECTION 1: CURRENT INFORMATION
Name Under Which Store is Doing Business (e.g., name on store signs)
Number of Cash Registers
Vendor Number
Telephone Number of Store
Store Street Address
City
Zip Code
Check all that apply:
Change of store location
Change in Corporate officers
Change in name
Change in manager(s)
Prices remain the same or have been reduced
Pharmacy to Grocery
Employees remain the same
Individual trained in the rules and regulations of the WIC Program remains the same
Other change (briefly describe):
New SNAP/Food Share 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 Doing Business Name and/or New Corporation, LLC, LLP, LP, etc.
Date of Name Change
SECTION 3: LOCATION CHANGE
New Store Street Address
P.O. Box
New Telephone Number of Store (if applicable)
City
Zip Code
Opening Date at New Location
Closing Date at Old Location
Number of Cash Registers
Distance from previous location (in miles)
Store Size (Check one):
Under 4,000 square feet
4,001 to 10,000 square feet
Over 10,000 square feet
SECTION 4: CHANGE IN ELECTRONIC CASH REGISTER (ECR) / POINT-OF-SALES (POS) SYSTEM / PROVIDER
ECR/POS Name
Version
ECR / POS Contact Name
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
DHS 149 Wis. Admin. Code
F-40108 (04/2017)
(608) 266-6912
RETAIL VENDOR APPLICATION AMENDMENT
WISCONSIN WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM
This form must be completed whenever a change occurs that affects the current agreement between the vendor and the State of
Wisconsin WIC Program. Examples of changes include a change in location, management or corporate officers. The completed form,
when approved by the State WIC Vendor Management, becomes an amendment to the vendor agreement between the vendor and the
State of Wisconsin WIC Program. All other conditions of the vendor agreement remain the same.
The authority for requesting and using personally identifiable information, including your Social Security number, is §253.06(3) Wis
Stats. Disclosure of your Social Security number is voluntary. Failure to complete the form may delay processing of the amendment.
Information, including the Social Security number, will be used to investigate continuing eligibility of WIC authorization, and may be
disclosed to federal, state and local law enforcement agencies, and federal and state tax authorities.
This form may not be used when there is a change of ownership of an authorized WIC vendor. When a change of ownership
occurs, the former owner must be terminated from the program and the new owner must submit a complete Retail Vendor Application.
Contact the State WIC Vendor Management for the forms or you may download the forms by going to www.dhs.wisconsin.gov/wic/.
INSTRUCTIONS: Type or print using blue or black ink. Complete the "Current Information" section, the "Certification" section, and all
sections that apply to the change. Submit the completed form to the WIC Vendor Management, P.O. Box 2659, Madison, WI 53701-
2659.
SECTION 1: CURRENT INFORMATION
Name Under Which Store is Doing Business (e.g., name on store signs)
Number of Cash Registers
Vendor Number
Telephone Number of Store
Store Street Address
City
Zip Code
Check all that apply:
Change of store location
Change in Corporate officers
Change in name
Change in manager(s)
Prices remain the same or have been reduced
Pharmacy to Grocery
Employees remain the same
Individual trained in the rules and regulations of the WIC Program remains the same
Other change (briefly describe):
New SNAP/Food Share 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 Doing Business Name and/or New Corporation, LLC, LLP, LP, etc.
Date of Name Change
SECTION 3: LOCATION CHANGE
New Store Street Address
P.O. Box
New Telephone Number of Store (if applicable)
City
Zip Code
Opening Date at New Location
Closing Date at Old Location
Number of Cash Registers
Distance from previous location (in miles)
Store Size (Check one):
Under 4,000 square feet
4,001 to 10,000 square feet
Over 10,000 square feet
SECTION 4: CHANGE IN ELECTRONIC CASH REGISTER (ECR) / POINT-OF-SALES (POS) SYSTEM / PROVIDER
ECR/POS Name
Version
ECR / POS Contact Name
P-40108
Page 2 of 2
SECTION 5: CORPORATE AGENT OR OFFICER(S)
– Refer to the Vendor Profile for current WIC ownership information and update below. Use
separate page and attach if more member/officer space is needed
New Corporate Agent
New Corporate Officer(s)
Corporate Agent Name (First, Middle Initial, Last)
Telephone (if different from above)
Full Name and Position Held (e.g., Name, President)
Check one
Social Security No.
Date of Birth
% of Ownership
Effective Date
New
Inactive
Full Name and Position Held (e.g., Name, President)
Check one
Social Security No.
Date of Birth
% of Ownership
Effective Date
New
Inactive
Full Name and Position Held (e.g., Name, President)
Check one
Social Security No.
Date of Birth
% of Ownership
Effective Date
New
Inactive
Full Name and Position Held (e.g., Name, President)
Check one
Social Security No.
Date of Birth
% of Ownership
Effective Date
New
Inactive
SECTION 6: MANAGER(S)
– Refer to the Vendor Profile for current WIC manager information and update below. If more than 5 manager updates,
submit information on a separate page.
Manager Name (First, Middle Initial, Last)
Check one
Social Security Number
Date of Birth
Effective Date
New
Inactive
Manager Name (First, Middle Initial, Last)
Check one
Social Security Number
Date of Birth
Effective Date
New
Inactive
Manager Name (First, Middle, Initial, Last)
Check one
Social Security Number
Date of Birth
Effective Date
New
Inactive
Manager Name (First, Middle, Initial, Last)
Check one
Social Security Number
Date of Birth
Effective Date
New
Inactive
SECTION 7: BUSINESS CONTACT INFORMATION
Person WIC Should Contact
Contact Person’s Title
Contact Person’s E-mail Address
Work Telephone Number
Cell Telephone Number
Fax Number
SECTION 8: CERTIFICATION
1. I certify that the information submitted on the form is accurate and complete. I affirm that I have authority to contract for the business. I understand
that the terms and conditions agreed to in the original agreement remain unchanged.
Full Name and Title of Individual Completing this Form (Type or Print):
Last Name
First Name
Middle Initial
Title
SIGNATURE – Individual Completing this Form
Date Signed
2. If the individual completing this form is not an owner, corporate officer, or other individual authorized to sign on behalf of the vendor, then the owner,
manager or other individual authorized to sign on behalf of the vendor must sign below.
Full Name and Title of Owner, Corporate Officer or Other Authorized Individual (Type or Print):
Last Name
First Name
Middle Initial
Title
SIGNATURE – Corporate Officer or Other Authorized Individual
Date Signed
RESET FORM
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