Application

Well WIC Worksite Re-Certification Form
To qualify for re-certification, your agency MUST have been certified for at least three years. Please complete and submit this form to maintain your agency’s active WIC Worksite Wellness certification.
Primary Agency Contact:

First Name Last Name
Email Address
example@example.com
Wellness Coordinator (if different from Primary Agency Contact)

First NameLast Name
Wellness Coordinator Email (if different from Primary Agency Contact)
example@example.com
Agency:
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeUnited States
Phone Number
Format: (000) 000-0000.
Original Certification Date (if known)
Example: 03/13/18
The following MUST be fulfilled in order to be re-certified for the WIC Worksite Wellness Program. Once this is completed and verified, your agency will receive a Re-Certification Certificate.
Provide a brief summary of the chosen objectives from the 10 Steps Guide and share their impact on your agency’s well-being.
Please attach your Wellness Summary document

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Upload additional files or supporting documents here:

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Congratulations!

Once we receive this form and your summary, we will send you an email confirmation that your agency has been recertified. We look forward to recertifying your agency and acknowledging all your successes as a Recertified Well WIC Worksite! Please email Jenniffer Duran-West at jduranwest@calwic.org with questions
Signature
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Well WIC Worksite Re-Certification Form