{"id":211,"date":"2017-07-18T18:56:19","date_gmt":"2017-07-18T18:56:19","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/wic-retailers\/?page_id=211"},"modified":"2026-05-12T17:31:18","modified_gmt":"2026-05-12T17:31:18","slug":"retailer-supply-request-form","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/wic-retailers\/retailer-supply-request-form\/","title":{"rendered":"Retailer Supply Request Form"},"content":{"rendered":"<h2><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-215 alignleft\" src=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/44\/2017\/07\/ewic.png\" alt=\"\" width=\"172\" height=\"114\" \/><br \/>\nVirginia WIC Program<br \/>\nRetailer Supply Request Form<\/h2>\n<hr style=\"clear: both;\" \/>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' ><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/wic-retailers\/wp-json\/wp\/v2\/pages\/211' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_2_31\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p style=\"font-size:17px;color:red\">Please enter the quantity for the items desired (1-99), complete the Contact Information, and select the \u201cSubmit\u201d button.<\/p>\n<hr><\/li><li id=\"field_2_39\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_39'><span class='gform-field-label__text'>WIC Approved Food Brochure (FDLST-24E) \u2013 English+<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_2_39' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'><span class='gform-field-label__text'>WIC Approved Food Brochure (FDLST-24S) \u2013 Spanish+<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_41\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_41'><span class='gform-field-label__text'>Formula Flyer (FORM LST-24-ES) \u2013 English and Spanish+<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_2_41' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_42\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_42'><span class='gform-field-label__text'>eWIC Accepted Here \u2013Door decal*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_2_42' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_43\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_43'><span class='gform-field-label__text'>eWIC Cashier Handbook  (VEN-125)+<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_44\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_44'><span class='gform-field-label__text'>Wholesome Informed Choices Shelf Labels (Option #3, 100 @ 1\u00bd\u201d x 2\u00bd\u201d )<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_2_44' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_46'><span class='gform-field-label__text'>Wholesome Informed Choices Shelf Labels (Option #4, 100 @ 1\u00bc \u201d x 1\u00bd \u201d)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_45\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'><span class='gform-field-label__text'>Retailer Incident\/Complaint Form (WIC #387)+<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_47\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'><span class='gform-field-label__text'>UPC Update Request Form<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_2_47' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_48'><span class='gform-field-label__text'>2022 WIC Program Retailer Manual\/Guidelines (VEN-002)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_49'><span class='gform-field-label__text'>2017 Cashier Training DVD  format w\/training aid<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_2_49' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_50\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_50'><span class='gform-field-label__text'>2017 Cashier Training USB format w\/training aid.<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_51\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_51'><span class='gform-field-label__text'>1-877-TELL-WIC tear-off pad (WIC-54E\/S)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_2_51' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'><span class='gform-field-label__text'>Comment<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='100' data-text-counter-template='{current} of {max} max characters'><textarea name='input_24' id='input_2_24' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_34\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contact Information<\/h2><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'><span class='gform-field-label__text'>Ship to Attention of<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'><span class='gform-field-label__text'>Order Date<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='08\/13\/2026'\n\t\t\t\t\tid='input_2_20'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_20'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_20' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_20' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_20' aria-label='Order Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'><span class='gform-field-label__text'>Store Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'><span class='gform-field-label__text'>WIC ID<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='medium'    placeholder='9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"9999\"\/><\/div><\/li><li id=\"field_2_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_35'><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_2_35' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_36'><span class='gform-field-label__text'>City<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_37\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'><span class='gform-field-label__text'>State<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='Virginia' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'><span class='gform-field-label__text'>Zip Code<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'    placeholder='99999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"99999\"\/><\/div><\/li><li id=\"field_2_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='medium'    placeholder='(999) 999-9999? x99999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999? x99999\"\/><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_19' id='input_2_19' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_29\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_29'><span class='gform-field-label__text'>Alternate Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_29' id='input_2_29' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_52\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_52'><span class='gform-field-label__text'>CAPTCHA<\/span><\/label><div id='input_2_52' class='ginput_container ginput_recaptcha' data-sitekey='6Lc8nmYUAAAAANY0fD8OEQqIfRpo8BtCxDj3PPA0'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer left_label'> <button type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='EzwBc5S50jPIck+NFGAGezylXbP+7L0dN7kUdt2ujMEmNz\/Qwh44G7fffI9TTIgNPrPjwHK34QUKTnUxk9WMJWr3SW+Sts5doeMLqvPGnGw3NRE=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n<hr \/>\n<h3>+Downloads are available online at:<\/h3>\n<h3><a href=\"https:\/\/www.vdh.virginia.gov\/wic-retailers\/resources\">https:\/\/www.vdh.virginia.gov\/wic-retailers\/resources<\/a><\/h3>\n<h3><strong>Contact your assigned Vendor Liaison if this order is not received within two weeks.<\/strong><\/h3>\n<p>*Additional supplies e.g. Door decals, lane signage, etc. can be ordered directly through the eWIC Processor.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Virginia WIC Program Retailer Supply Request Form +Downloads are available online at: https:\/\/www.vdh.virginia.gov\/wic-retailers\/resources Contact your assigned Vendor Liaison if this order is not received within two weeks. *Additional supplies e.g. Door decals, lane signage, etc. can be ordered directly through the eWIC 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