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Get California Wic Form

FAX: (916) 928-4759 WIC MATERIALS FOR AUTHORIZED VENDORS All store information below is required. Print clearly. VENDOR NUMBER: (6-digit number) ** VENDOR STORE NAME: (not corporate name) DELIVERY ADDRESS: (DO NOT USE PO BOX, street address only) CITY, STATE, ZIP: CONTACT PHONE NUMBER: ( NEW CONTACT?: (check if yes) CONTACT NAME: (First, Last Name) ) - CONTACT SIGNATURE: ** If you do not enter your 6-digit vendor number, your order will not be filled! Refer to first page of your Vendo.

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