DC WIC Vendor and Manufacturer Support Form
Please use this form to report an issues that require DC WIC state agency support.
Company Name:
*
Representative Name:
*
First Name
Last Name
Role:
*
Rep. E-mail:
*
example@example.com
Rep. Phone Number:
*
Please enter a valid phone number.
Store Number and Address (if applicable):
Are you a:
*
WIC Vendor
Manufacturer
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WIC Vendor
Please select an issue type:
*
WIC Shopping Issue/ Customer Issue
Item should be approved but not going through (APL related issue)
Transaction processing/technology
Supplies Request
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WIC Vendor Support Form - WIC Issue/Customer Issue
Date of Issue:
*
-
Month
-
Day
Year
Date
Time (approx.) of issue:
*
Please describe the issue with as much detail as possible:
*
What follow up/action are you requesting from the DC WIC State Agency?
*
Attach supporting documentation:
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WIC Vendor Support Form - Item should be approved but not going through (APL related issues)
Date of Issue:
*
-
Month
-
Day
Year
Date
Time (approx.) of issue:
*
Item Description (Brand, size, variety):
*
Item UPC:
Please describe the issue with as much detail as possible:
*
Attach supporting documentation:
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WIC Vendor Support Form - Transaction Processing/technology issue
Date of issue:
*
-
Month
-
Day
Year
Date
Is this issue still occurring?
*
What WIC point-of-sale system did the issue occur with?
*
Integrated system (processes different forms of payment incl. WIC, SNAP, Cash/credit, etc.)
Stand Beside Device (processes WIC only)
If you are using an integrated system, did you contact corporate or the POS provider?
*
If you are using a stand beside device, did you contact FIS (1-877-291-0433)?
*
Please describe the issue with as much detail as possible:
*
What follow up/action are you requesting from the DC WIC State Agency?
*
Attach supporting documentation:
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What supplies are needed?
*
Quantity needed?
*
When do you need it by?
*
-
Month
-
Day
Year
Date
Where should the materials be sent?
*
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Manufacturer
Please provide a brief description of the item updates you are submitting:
File Upload:
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Should be Empty: