Application for Vendor Authorization

This form should be used for both initial authorization and re-authorization (required every three years). Please allow 30 days for a decision on your application.

Print Friendly Application
(Adobe PDF*)

* required fields

*Type of request (Required)



*Type of authorization (check one)(Required)

(grocery store licensed by the Maine Department of Agriculture that has no pharmacy on its premises)
(food store and pharmacy under the same ownership on the same premises)
(registered pharmacy through the Maine Commission of Pharmacies that is not operating as a food vendor)

Store Information

Does the applicant own the real estate where the store is located?
Do cash registers use optical scanning devices that record product and price information on customer receipts?
Do cash registers flag WIC items?
*Will you derive more than 50 percent of your annual food sales from the sale of WIC foods? (Required)
Is your store in a permanent, fixed location?
Is your store authorized to accept SNAP benefits (formerly known as food stamps)? (Required)
Does your store have a valid food establishment license issued by the Maine Department of Agriculture or its equivalent in New Hampshire?
Ownership type:






Sales Information

Use tax returns or, for new stores, projections to determine these numbers.

Suppliers

Please give name and address for all that apply.

Services

Please check all that apply.













Business Integrity

Has the corporate entity, current owner, officer, manager or any other individual who directly or indirectly participates in the operation of the store ever been denied participation, cited for non-compliance, involuntarily withdrawn, been disqualified or fined by the SNAP (Food Stamp) program within the past six years, or ever been permanently disqualified, in Maine or any other state?

Has the corporate entity, current owner, officer, manager or any other individual who directly or indirectly participates in the operation of the store ever been convicted of, or had a civil judgment entered against him/her for fraud, antitrust violations, embezzlement, theft, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims, or obstruction of justice?

By typing my name below, I certify that I have the authority to contract for the business and all information submitted on this form is accurate and complete. I understand that this application does not guarantee selection and authorization to participate in the Maine WIC Nutrition Program. The prices listed are my current, actual shelf prices. No conflict of interest exists between my business and any WIC agency. I understand that if this store is selected for authorization, I will be bound by the rules and regulations of the WIC program.

After you have submitted your application, please proceed to the Price Survey (PDF) page, download a survey form and follow the instructions on it. Thank you!