WIC Vendor Complaint Form

Vendor or Grocery Name

Vendor Number

(Only applicable if a Vendor)

Vendor or Grocery Owner Name

(First)

(Last)

Vendor or Grocery Address

City

State

Zip Code

Vendor or Grocery Telephone Number

(Please enter the phone number in XXX-XXX-XXXX format)

In the box below, please provide a description of the complaint against the WIC Vendor or Grocer. Be sure to include the important details such as names of persons suspected and dates if available.

Have you ever filed a complaint against this Vendor?

Yes

WIC Vendor Complaint Description:

Date of Incident

Time of Day (if applicable)

(Time Format Example: 2:00 pm)

You are able to file a WIC Vendor Complaint anonymously, but if you would like the WIC State Agency to contact you, please complete the fields below:

Name

Telephone Number

E-Mail Address

Accessibility