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Get STAFF COMMUNICATION FORM

New Food Package Code: __________ □ Customized Food Package: Line item Delete the following foods: Infants (6–11 months) □ Infant cereal □ Infant food Children (1–5 Years) and Women □ Milk □ Eggs □Cereal □ Juice □ Beans □ Cheese □ Peanut butter □Whole grain □ Fruits/Vegetables NEXT APPOINTMENT FOR: CL SC PC BFPC CERTIFYING AUTHORITY INITIALS ____________ RD OTHER__________ DATE:___________________ (CIRCLE ONE) .

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