WIC Pre-Application Information Online

Please fill in the blanks and select the appropriate answer to assist in making your application. Click SUBMIT and someone will contact you. Thank you!

Last:

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Preferred Language:



What is your family's monthly income BEFORE taxes?

Address Line 2:
State / Province / Region:
Postal / Zip Code:

Address Line 2:
State / Province / Region:
Postal / Zip Code:

- -

Additional Applicants
(Pregnant, breastfeeding, or postpartum woman, and children in the home under the age of 5 years) :

Name of Person #1

Last:

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Name of Person #2

Last:

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Name of Person #3

Last:

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Background Information

If YES, when?

If YES, where? When?