WIC Vendors - Pharmacy

Forms for applicants
Forms for authorized vendors

Any owner of a pharmacy located in Wisconsin may apply for authorization as a WIC pharmacy vendor. WIC authorization does not transfer to a new owner when a change of ownership occurs. Vendors shall not accept drafts until all application requirements are met, including completing forms and submitting supporting documents, passing a site visit, completing a training program and receiving an authorization letter from the WIC Program. Completion of the application does not guarantee WIC vendor authorization. Submission of false information will result in denial of the application.

Conditions of Eligibility Vendor Must Meet

1. An acceptable history with WIC and other food and nutrition service programs of the USDA.
2. Charge a price for infant formula which is comparable to the average price charged by other vendor applicants in the project service area in which the pharmacy is located, as determined by the state WIC office.
3. Have a satisfactory site visit by the state or local WIC project wherein it is determined that:

1. prices are marked on the food containers or posted in the immediate area where foods are kept in the customer area of the store;
2. prices are not substantially higher than those listed on the application;
3. the store is not in violation of applicable federal, state or local health protection laws and ordinances;
4. authorized foods are not older than the expiration date indicated on the package or are otherwise fresh.

4. Following an acceptable site visit, participate in a training program at a location designated by local WIC Project staff. A signed contract, authorization letter, vendor stamp, and educational materials will be distributed at the training session.

Duration of Authorization

The Wisconsin WIC Program has a three-year authorization contract period. Refer to the Agreement Between the State of Wisconsin and the Vendor (see below) for details on the current contract period. If the vendor wishes to continue to be authorized beyond its current agreement, the vendor must reapply for authorization.

Application Materials

• WIC Vendor Welcome and Application Materials (PDF, 44 KB) 

• Wisconsin WIC Program Retail Vendor Application. (Word, 220 KB) 
  The application is now Word-fillable. Print a copy of the completed application, apply the required signature, and have it notarized. Maintain a photocopy of the completed application for your records.

• Food Sales Fact Sheet (PDF, 78 KB) 
  To assist in calculating and documenting annual Total Food Sales on vendor application and during authorization.

• Pharmacy Stock Price Survey. (PDF, 13 KB) 
  Photocopy each page of the completed stock price survey for your records.

• Agreement Between the State of Wisconsin and the Vendor. (PDF, 27 KB) 
  Submit TWO copies. Both copies must be signed and returned. When the store is authorized, a copy signed by the Department will be returned.

• WIC Authorized Infant Formula Suppliers. (PDF, 12 KB) (Effective 11/11)  

Other Documents Required

1. Proof of ownership of business and/or building. Examples of proofs include, but are not limited to:

   • Bill of sale.

   • Lease agreement (business and/or building).

   • Franchise agreement.

   • Offer to purchase or purchase agreement (business and/or building).

   • Deed.

2. Copy of the Pharmacy License.

3. Required registration with the Wisconsin Department of Financial Institutions (DFI). Any corporation or partnership must be registered with DFI and be in good standing. Go to www.wdfi.gov for more information.

4. If your store has been open and operating for more than six months, provide copies of the four most recent months of Wisconsin Sales and Use Tax Forms (Form ST-12) filed.

Regulations, Statutes and Administrative Rules

• WIC Vendor Manual (PDF, 2.6 MB) (Large file; may download slowly) 

• Title 7 CFR Part 246 as of January 1, 2005. (PDF, 297 KB)
  Or search for "7CFR246" in the online Code of Federal Regulations. (exit DHS)

• Section 253.06, Wisconsin Statutes. Scroll down to page 2 for the WIC section. (exit DHS)   

• Chapter HFS 149, Wisconsin Administrative Code. 

Determination Period

Applications are reviewed within 90 days of receipt of complete applications. If the application is not complete, a notice of incomplete items will be sent and the application will not be processed further. An application returned due to incompleteness may, following completion, be resubmitted within 15 days to the State WIC Office, or a new application may be submitted at any time.

Forms for Authorized Vendors

• WIC Vendor Participant Complaint, F-44322 (PDF, 88 KB)

• WIC Vendor Supplies Request, F-44444 (Word, 54 KB)

• WI WIC Retail Vendor Application Amendment, F-40108 (PDF, 17 KB)
  Use this form to update your application information after it has been approved. 

Department Contact

WIC Vendor Integrity
PO Box 2659
Madison, WI 53701-2659
(608) 266-6912

Back to "How to Become a WIC Vendor"
Back to the WICPRO home page

PDF: The free Adobe Reader^® software is needed to view and print portable document format (PDF) files. Learn more.

Last Revised:  January 03, 2012