8
Louisiana WIC Vendor Initial Application Resources and Checklist Vendor Name: Application Date: Instructions: Use the resources below to assist you in completing the Louisiana WIC Vendor Application. Incomplete Vendor Applications and/or Vendor Applications submitted without all required documentation will not be accepted. If you have questions, contact us at (504) 568-8229 or [email protected]. SECTION I – LA WIC Vendor Application Information and Resources For assistance completing the Louisiana WIC Vendor Application, please visit the Louisiana WIC Vendor website. LA WIC Vendor Application LA WIC Vendor Agreement LA WIC Vendor Guide LA WIC Approved Infant Formula Provider List LA WIC Statewide Average Prices LA WIC Food Sales Facts Sheet Grocer’s Price Report Sheet (WIC-3) Signature Authority Letters o LA WIC Signature Authority Letter (for use by LLCs, Limited Liability Partnership, Partnership, Sole Proprietorship) o LA WIC Written Resolution of the Board of Directors (for use by Corporations) SECTION II – LA WIC Vendor Application Checklist All documents listed below must be submitted with your application. Completed, signed, and notarized Vendor Application (version dated 10/2020) Signed, initialed, and dated Vendor Agreement (version dated 10/2020) The same person signed both the Vendor Application and the Vendor Agreement The person signing the Application and Agreement has signature authority OR the appropriate signature authority document (listed above) is included with the application packet. Copy of valid Louisiana Grocery Retail Permit labeled “Permanent Grocery/Market”. See example. Copy of SNAP authorization. See example. Completed, signed, and dated WIC-3 (version dated 10/2020) Copy of Photo ID of owners, partners, or corporate officers Copy of parish sales tax forms from the previous quarter Complete application packets must be mailed to: LDH/OPH/Bureau of Nutrition Services Vendor Operations Unit P.O. Box 60630 New Orleans, LA 70160

Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

  • Upload
    others

  • View
    0

  • Download
    0

Embed Size (px)

Citation preview

Page 1: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

Louisiana WIC Vendor Initial Application Resources and Checklist

Vendor Name: Application Date:

Instructions: Use the resources below to assist you in completing the Louisiana WIC Vendor Application. Incomplete Vendor Applications and/or Vendor Applications submitted without all required documentation will not be accepted. If you have questions, contact us at (504) 568-8229 or [email protected].

SECTION I – LA WIC Vendor Application Information and Resources

For assistance completing the Louisiana WIC Vendor Application, please visit the Louisiana WIC Vendor website.

• LA WIC Vendor Application• LA WIC Vendor Agreement• LA WIC Vendor Guide• LA WIC Approved Infant Formula Provider List• LA WIC Statewide Average Prices• LA WIC Food Sales Facts Sheet• Grocer’s Price Report Sheet (WIC-3)• Signature Authority Letters

o LA WIC Signature Authority Letter (for use by LLCs, Limited Liability Partnership, Partnership, SoleProprietorship)

o LA WIC Written Resolution of the Board of Directors (for use by Corporations)

SECTION II – LA WIC Vendor Application Checklist All documents listed below must be submitted with your application.

☐ Completed, signed, and notarized Vendor Application (version dated 10/2020)☐ Signed, initialed, and dated Vendor Agreement (version dated 10/2020)

☐ The same person signed both the Vendor Application and the Vendor Agreement☐ The person signing the Application and Agreement has signature authority OR the appropriate signature

authority document (listed above) is included with the application packet.☐ Copy of valid Louisiana Grocery Retail Permit labeled “Permanent Grocery/Market”. See example.☐ Copy of SNAP authorization. See example.☐ Completed, signed, and dated WIC-3 (version dated 10/2020)☐ Copy of Photo ID of owners, partners, or corporate officers☐ Copy of parish sales tax forms from the previous quarter

Complete application packets must be mailed to: LDH/OPH/Bureau of Nutrition Services

Vendor Operations Unit P.O. Box 60630

New Orleans, LA 70160

Page 2: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

/RXLVLDQD�'HSDUWPHQW�RI�+HDOWK-�2IILFH�RI�3XEOLF�+HDOWK-�%XUHDX�RI�1XWULWLRQ�6HUYLFHV

7KH�6SHFLDO�6XSSOHPHQWDO�1XWULWLRQ�3URJUDP�IRU�:RPHQ��,QIDQWV�DQG�&KLOGUHQ��:�,&�� 9(1'25�$33/,&$7,21

&RPSOHWLRQ� RI� WKLV� IRUP� LV� UHTXLUHG� WR� EH� FRQVLGHUHG� IRU� DXWKRUL]DWLRQ� DV�D�/RXLVLDQD�:,&���/$�:,&��9HQGRU��7KH� VXEPLVVLRQ�RI� WKLV� DSSOLFDWLRQ� GRHV� QRW�JXDUDQWHH�YHQGRU�DXWKRUL]DWLRQ�� ,QIRUPDWLRQ�RQ� WKH� DSSOLFDWLRQ�ZLOO� EH� XVHG� WR� DVVHVV�HOLJLELOLW\� RU�FRQWLQXLQJ�HOLJLELOLW\�IRU�:,&�DXWKRUL]DWLRQ��7KH�LQIRUPDWLRQ�PD\� EH� GLVFORVHG� WR� IHGHUDO�� VWDWH� DQG� ORFDO� ODZ� HQIRUFHPHQW�DJHQ�FLHV� DQG� IHGHUDO� DQG� VWDWH� WD[� DXWKRULWLHV� IRU� WKH�SXUSRVHV�RI�HOLJLELOLW\�GHWHUPLQDWLRQ��ODZ�HQIRUFHPHQW�DQG�FROOHFWLRQ�RI� IRUIHL�WXUHV�� UHFRXSPHQWV� DQG� IRUIHLWXUH� DVVHVVPHQWV��)DLOXUH� WR�SURYLGH�DQ\� LQIRUPDWLRQ�PD\� LQFUHDVH�WKH� WLPH�LW� WDNHV�WR�SURFHVV�\RXU�DSSOLFDWLRQ��DQG�RU�PDNH�WKH�DSSOLFDWLRQ�LQHOLJLEOH�IRU�UHYLHZ�

5HWXUQ�&RPSOHWHG�$SSOLFDWLRQV�WR�

/RXLVLDQD�'HSDUWPHQW�RI�+HDOWK 23+�–�%XUHDX�RI�1XWULWLRQ�6HUYLFHV�–�:,&�9HQGRU�8QLW 3��2��%R[������ 1HZ�2UOHDQV��/RXLVLDQD������

1RWH��2QO\�FRPSOHWHG��QRWDUL]HG�DSSOLFDWLRQV�ZLOO�EH�SURFHVVHG�

)25�/$�:,&�86(�21/<

7UDGH�$UHD��BBBBBBB��([SLUHV�LQ�<HDU��BBBBBBB

'DWH ,QLWLDOV

5HFHLYHG� �PP�GG�\\\\�

3DUW�����6725(�,1)250$7,21 PH�6WRUH�LV�'RLQJ�%XVLQHVV�$V��'%$�� �/HJDO� PH�RI�6WRUH�

��6WRUH�7\SH ��FKHFN�RQH�� �*URFHU\��� &RQYHQLHQFH��� +\SHUPDUNHW���

�:,&�9HQGRU�1XPEHU�� ��,I�&XUUHQWO\�:,�&�$XWKRUL]HG��

�3DULVK�

�6WRUH�7HOHSKRQH�1XPEHU� �6WRUH�)D[�1XPEHU� �%XVLQHVV�)HGHUDO�7D[� '�1XPEHU�

�6WRUH�6WUHHW�$GGUHVV��3K\VLFDO�/RFDWLRQ�� �&LW\� �6WDWH� �=,3�&RGH�

�0DLOLQJ�$GGUHVV��,I�'LIIHUHQW�)URP�$ERYH�� �&LW\� �6WDWH� �=,3�&RGH�

��'HVFULSWLRQ�RI�6WRUH��,QFOXGLQJ�'LUHFWLRQV��,I�1RW�(DVLO\�,GHQWLILDEOH�

6WRUH� 7\SHV�� � D��*URFHU\� LV� D� UHWDLO� VWRUH� WKDW� SULPDULO\� VHOOV� IRRG�� E��&RQYHQLHQFH� LV� D� VPDOO� VWRUH� ZLWK� H[WHQGHG� RSHQLQJ� KRXUV� DQG� LQ� D���������FRQYHQLHQW�ORFDWLRQ��VWRFNLQJ�D�OLPLWHG�UDQJH�RI�KRXVHKROG�JRRGV�DQG�JURFHULHV��F��+\SHUPDUNHW�LV�D�VXSHUVWRUH�FRPELQLQJ�D�VXSHUPDUNHW�JURFHU\�DQG�D�GHSDUWPHQW�VWRUH�

&217$&7�3(5621�6���3OHDVH�OLVW�DOO�SHUVRQV�UHVSRQVLEOH�IRU�WKH�GD\-WR-GD\��RQ-VLWH�RSHUDWLRQV�RI�WKLV�VWRUH��LQFOXGLQJ�WKH�RZQHU� LI� WKH\� DFW� LQ� WKLV� FDSDFLW\���7KH�ILUVW�SHUVRQ� LGHQWLILHG�VKRXOG�EH�WKH�SULPDU\�FRQWDFW�IRU�/$�:,&�� 3OHDVH�VKRZ�QDPHV�DV�WKH\�DSSHDU�RQ�OHJDO�GRFXPHQWV�

��� �1DPH��/DVW��)LUVW�0LGGOH���3ULPDU\�&RQWDFW�� �7LWOH�

��&RQWDFW�3HUVRQ¶V�(PDLO�$GGUHVV� �&RQWDFW�3HUVRQ¶V�7HOHSKRQH�1XPEHU��,QFOXGLQJ�$UHD�&RGH��

��� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

��&RQWDFW�3HUVRQ¶V�(PDLO�$GGUHVV� �&RQWDFW�3HUVRQ¶V�7HOHSKRQH�1XPEHU��,QFOXGLQJ�$UHD�&RGH��

��� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

��&RQWDFW�3HUVRQ¶V�(PDLO�$GGUHVV� �&RQWDFW�3HUVRQ¶V�7HOHSKRQH�&HOO�1XPEHU��,QFOXGLQJ�$UHD�&RGH��

3DJH���RI�� /RXLVLDQD�'HSDUWPHQW�RI�+HDOWK 2IILFH�RI�3XEOLF�+HDOWK /$�:,&�9� QGRU�$SSOLFDWLRQ��5HY��10������

Page 3: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

3DUW�����2:1(56+,3�,1)250$7,21

����$��2ZQHUVKLS�7\SH��&KHFN�RQH��*R�WR�https://coraweb.sos.la.gov/commercialsearch/commercialsearch.aspx�IRU� DVVLVWDQFH�LQ�GHWHUPLQLQJ�RZQHUVKLS�W\SH��

��6ROH�3URSULHWRU ��/LPLWHG�/LDELOLW\�&RPSDQ\��//&� ��/LPLWHG�/LDELOLW\�3DUWQHUVKLS �//3�

��&RUSRUDWLRQ ��/LPLWHG�3DUWQHUVKLS��/3� ��3DUWQHUVKLS�

���%��6ROH�3URSULHWRUVKLSV�RU�3DUWQHUVKLSV��LQFOXGLQJ�/3V��//3V���/LVW�DOO�UHJLVWHUHG�DJHQWV��RZQHUV�DQG�RU�SDUWQHUV�DQG��������SURYLGH�WKH�KRPH�DGGUHVV�DQG�SKRQH�QXPEHU��V��IRU�HDFK��,I�PRUH�VSDFH�LV�QHHGHG��SOHDVH�FRPSOHWH�D�VHSDUDWH�SDJH�DQG�DWWDFK�LW�WR�WKLV�DSSOLFDWLRQ�

���� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

�'DWH�RI�%LUWK��PP�GG�\\\\�� �3HUFHQW�RI�2ZQHUVKLS�� ��$GGUHVV�

�&LW\� �6WDWH� �=,3�&RGH�

�:RUN�3KRQH� �&HOO�3KRQH�

���� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

�'DWH�RI�%LUWK��PP�GG�\\\\�� �3HUFHQW�RI�2ZQHUVKLS�� ��$GGUHVV�

�&LW\� �6WDWH� �=,3�&RGH�

�:RUN�3KRQH� �&HOO�3KRQH�

���� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

�'DWH�RI�%LUWK��PP�GG�\\\\�� �3HUFHQW�RI�2ZQHUVKLS�� ��$GGUHVV�

�&LW\� �6WDWH� �=,3�&RGH�

�:RUN�3KRQH� �&HOO�3KRQH�

���&���/LPLWHG�/LDELOLW\�&RPSDQLHV��//&��RU�&RUSRUDWLRQV��/LVW�DOO�UHJLVWHUHG�DJHQWV��FRUSRUDWH�RIILFHUV��RU�PHPEHU��V��DQG�SURYLGH�WKH�KRPH�DGGUHVV�DQG�SKRQH�QXPEHU��V��IRU�HDFK��,I�PRUH�VSDFH�LV�QHHGHG��SOHDVH�FRPSOHWH�D�VHSDUDWH�SDJH�DQG�DWWDFK�LW�WR�WKLV�DSSOLFDWLRQ�

���� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

�'DWH�RI�%LUWK��PP�GG�\\\\�� �

�$GGUHVV�

�&LW\� �6WDWH� �=,3�&RGH�

�:RUN�3KRQH� �&HOO�3KRQH�

���� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

�'DWH�RI�%LUWK��PP�GG�\\\\�� �

�$GGUHVV�

�&LW\� �6WDWH� �=,3�&RGH�

�:RUN�3KRQH� �&HOO�3KRQH�

���� �1DPH��/DVW��)LUVW�0LGGOH�� �7LWOH�

�'DWH�RI�%LUWK��PP�GG�\\\\�� �

�$GGUHVV�

�&LW\� �6WDWH� �=,3�&RGH�

�:RUN�3KRQH� �&HOO�3KRQH�

3DJH���RI�� /RXLVLDQD�'HSDUWPHQW�RI�+HDOWK2IILFH�RI�3XEOLF�+HDOWK /$�:,&9HQGRU�$SSOLFDWLRQ��5HY��10������

Page 4: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

�'��2WKHU�6WRUH�2ZQHUVKLS�'LVFORVXUH��)RU�RWKHU�VWRUHV�RZQHG�E\�WKH�VDPH�RZQHU�PDNLQJ�WKLV�DSSOLFDWLRQ��VROH�SURSULH�WRUVKLS��SDUWQHUVKLS�� OLPLWHG�SDUWQHUVKLS�� OLPLWHG� OLDELOLW\�SDUWQHUVKLS��FRUSRUDWLRQ��RU�OLPLWHG�OLDELOLW\�FRPSDQ\��� OLVW�EHORZ�

�� $Q\�RWKHU�:,&�DXWKRUL]HG�VWRUHV�ORFDWHG�LQ�WKH�6WDWH�RI�/RXLVLDQD��DQG�LQGLFDWH�LI�DQ\�KDYH�EHHQ�GHWHUPLQHG�WR�EH�$ERYH-���9HQGRUV��D�VWRUH�WKDW�GHULYHV��RU�LV�H[SHFWHG�WR�GHULYH��PRUH�WKDQ�����RI�DQQXDO�IRRG�VDOHV�IURP�:,&�WUDQVDFWLRQV��

�� $Q\�:,&�DXWKRUL]HG�VWRUHV�ORFDWHG�RXWVLGH�RI�WKH�6WDWH�RI�/RXLVLDQD�WKDW�KDYH�EHHQ�GHWHUPLQHG�WR�EH�$ERYH-���9HQGRUV���,I�PRUH�VSDFH�LV�QHHGHG��SOHDVH�FRPSOHWH�D�VHSDUDWH�SDJH�DQG�DWWDFK�LW�WR�WKLV�DSSOLFDWLRQ�

�6WRUH�1DPH� �6WRUH�$GGUHVV� �:,&�9HQGRU���DQG�6WDWH���QRW�/RXLVLDQD��LI�&XUUHQWO\��$XWKRUL]HG

,V� 6WRUH� $ERYH-��� IRU�:,&� �LQFOXGLQJ� LQ� DQ�RWKHU�6WDWH�

)16�61$3�,'��� �LI�&XUUHQWO\�$XWKRU�L]HG�

�3DUW�����6725(�+,6725<

����$��:KHQ�GLG�WKH�VWRUH�RSHQ�RU�ZKHQ�LV�LW�VFKHGXOHG�WR�RSHQ�IRU�EXVLQHVV�XQGHU�$SSOLFDQW¶V�RZQHUVKLS"� ��PP�GG�\\\\�

��6HFWLRQV�%�DQG�&�VKRXOG�RQO\�EH�FRPSOHWHG�E\�DQ�DSSOLFDQW�ZKR�LV�D�QHZ�YHQGRU�VWRUH�DSSO\LQJ�IRU�DXWKRUL]DWLRQ�

�����%��:DV�WKHUH�D�JURFHU\��VWRUH�EXVLQHVV�DW�WKLV�ORFDWLRQ�SU LRU �WR�WKH�FXU UHQW�RZQHUVKLS"

���1R�� �����<HV��WKHQ�FRPSOHWH�WKH�VHFWLRQV�EHORZ�

�3UHYLRXV�%XVLQHVV�1DPH� 1DPH��V��RI�3UHYLRXV�2ZQHU��V�� �:DV�WKH�EXVLQHVV� �:,&�$XWKRUL]HG" ����<HV�� ����1R

'DWH�RI� FKDQJH�RI�RZQHUVKLS�RU�ODVW�NQRZQ�GDWH�WKDW�WKH�VWRUH�ZDV�RSHQ��ZKLFKHYHU�LV�ODWHU���

�PP�GG�\\\\��___________

�����&��3ULRU�5HODWLRQVKLS�'LVFORVXUH��'R�DQ\�RI�WKH�RZQHUV��PDQDJHUV�RU�HPSOR\HHV�KDYH�DQ\�UHODWLRQVKLS�ZLWK�WKH�SUHYLRXV�EXVL�QHVV�RZQHUV"�$�UHODWLRQVKLS�ZRXOG�LQFOXGH��EXW�LV�QRW�EH�OLPLWHG�WR���EXVLQHVV�SDUWQHU��VKDUH�VWRFN�KROGHU��PHPEHU�RI�LPPHGL�DWH�RU�H[WHQGHG�IDPLO\��FRUSRUDWH�RIILFHU��PDQDJHU��HPSOR\HH�RU�RWKHU�W\SH�RI�UHODWLRQVKLS�� ����<HV�� �������1R���,I�\HV��FRP�SOHWH� WKH�QH[W�OLQHV�� ,I�PRUH�VSDFH�LV�QHHGHG��SOHDVH�FRPSOHWH�RQ�D�VHSDUDWH�SDJH�DQG�DWWDFK�LW�WR�WKLV�DSSOLFDWLRQ�

&XUUHQW�%XVLQHVV�3HUVRQ¶V�1DPH� ,V�:DV�5HODWHG�WR��LQFOXGH�QDPH�DQG�WLWOH�� +RZ"

3DJH���RI�� /RXLVLDQD�'HSDUWPHQW�RI�+HDOWK�� 2IILFH�RI�3XEOLF�+HDOWK /$�:,&�9� QGRU�$SSOLFDWLRQ��5HY��10�������

Page 5: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

3DUW�����6725(�23(5$7,21�6�,1�)250$7,�21

A. Louisiana 5HWDLO�3HUPLW�1XPEHU� B��6TXDUH�)HHW�RI�5HWDLO�6SDFH�

C��1XPEHU�RI�&DVK�5HJLVWHUV� D��+RZ�0DQ\�5HJLVWHUV�+DYH�6FDQQHUV"

Yes NoE��&DQ�WKH�Vcanners identify WIC-elligible Foods?

F��&DVK�5HJLVWHU�6\VWHP�DQG�6WRUH�3URFHGXUHV ����+DV�WKH�VWRUH¶V�UHWDLO�FDVK�UHJLVWHU�V\VWHP�EHHQ�/��FHUWLILHG�E\�/$�:,&"�� ����<HV�� �������1R

����,I�WKH�DQVZHU�WR����DERYH�LV�QR��GRHV�WKH�VWRUH�DFNQRZOHGJH�WKDW�LW�FDQQRW�EH�DXWKRUL]HG�XQWLO�LW�KDV�DFKLHYHG�/��FHUWLILFDWLRQ�E\�/$�:,&"��� ����<HV�� �������1R

����)RU�1HZ�$SSOLFDQWV�RQO\-3OHDVH�FRPSOHWH�WKH�IROORZLQJ�LQIRUPDWLRQ���D��1DPH�RI�326�3URYLGHU�BBBBBBBBBBBBBBBBBBBBBBBBBB� ��������E��1DPH�RI�326�6\VWHP��BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB���F��7\SH�RI�6\VWHP��������6WDQG-%HVLGH� �������,QWHJUDWHG

���'RHV�WKH�VWRUH�SURYLGH�LWHPL]HG�UHFHLSWV�WR�FXVWRPHUV�VKRZLQJ� D��'DWH�RI�SXUFKDVH" ����<HV�� �������1R E��'HVFULSWLRQ�RI� LWHP�SXUFKDVHG"��������������������������� ����<HV�� �������1R F��4XDQWLW\�RI�HDFK�LWHP�SXUFKDVHG"������������������������������� ����<HV�� �������1R G��7RWDO�VDOH�DPRXQW"��������������������������������������������������������� ����<HV�� �������1R

����'R�VWRUH�&DVK�UHJLVWHU��V��SHUIRUP�VSOLW�WHQGHU�WUDQVDFWLRQV��DFFHSW�FDVK�RU�RWKHU�IRUP�RI�SD\PHQW�"��������<HV���������1R

�/$�:,&�GHILQHV�D�FDVK�UHJLVWHU�DV�D�SRLQW-RI-VDOH�GHYLFH�WKDW�LV�FDSDEOH�RI�SURFHVVLQJ�D�:,&�WUDQVDFWLRQ�� 7KLV�LQFOXGHV�IL[HG�FDVK�UHJLVWHUV�DV�ZHOO�DV�DQ\�PRELOH�GHYLFHV�ZLWK�VLPLODU�FDSDELOLWLHV�WR�SURFHVV�D�UHWDLO�VDOHV�WUDQVDFWLRQ�

� G��'RHV�WKH�2ZQHU�RU�$SSOLFDQW�KDYH�$FFHV V�7R�DQG�8WLOL]H�

����� $�FRPSXWHU"��� ����<HV�� �������1R ����� 7KH�,QWHUQHW�VXFK�WKDW�LW�ZLOO�IDFLOLWDWH�FRPPXQLFDWLQJ�HOHFWURQLFDOO\�ZLWK�WKH�/$�:,&�3URJUDP�DV�ZHOO�DV�GRZQORDGLQJ�DQG�XSORDG�

LQJ�HOHFWURQLF�GRFXPHQWV�WR�IURP�WKH�:,&�3URJUDP"� ����<HV�� �������1R ����� $Q�H-PDLO�DFFRXQW�FDSDEOH�RI�VHQGLQJ�HOHFWURQLF�FRPPXQLFDWLRQV�WR�DQG�UHFHLYLQJ�IURP�WKH�/$�:,&�3URJUDP"� ���<HV� � ����1R

H��'D\V�DQG�+RXUV�RI�2SHUDWLRQ�

'$< )520��23(1� 72��&/26(� &+(&.�,)�23(1����+2856 6XQGD\ � 0RQGD\ � 7XHVGD\ �

:HGQHVGD\ � 7KXUVGD\ � )ULGD\ � 6DWXUGD\ �

I��,V�WKH�VWRUH�RSHQ�IRU�D�PLQLPXP�RI���GD\V�SHU�ZHHN��ZLWK�D�PLQLPXP�RI����KRXUV�RSHQ�WR�WKH�SXEOLF"������<HV���������1R

J�� 6XSSOLHU� ,QIRUPDWLRQ�� 3OHDVH� SURYLGH� WKH� QDPH� �V�� DQG� ORFDWLRQ� �V�� RI� \RXU�:KROHVDOHU� �V�� RU� 'LVWULEXWRU� �V��ZKHUH� :,&� IRRGV� DUH� SXUFKDVHG�� 3OHDVH� DOVR� LQGLFDWH� WKH� :KROHVDOHU��V�� RU� 'LVWULEXWRU��V�� ZKHUH� \RX� SXU�FKDVH� LQIDQW� IRUPXOD�� �8VH� WKH� ODVW� FROXPQ� WR� LQGLFDWH� WKLV� E\� PDUNLQJ� �;�� QH[W� WR� DOO� SURYLGHUV� ZKHUH� \RX�SXUFKDVH�LQIDQW�IRUPXOD��,I�PRUH�VSDFH�LV�QHHGHG��SOHDVH�FRPSOHWH�RQ�D�VHSDUDWH�SDJH�DQG�DWWDFK�LW�WR�WKLV�DSSOLFD�WLRQ��

:KROHVDOHU¶V�RU 'LVWULEXWRUV�1DPH

6WUHHW�$GGUHVV &LW\ 6WDWH =,3�&RGH 7HOHSKRQH )RUPXOD 3URYLGHU

3DJH���RI�� /RXLVLDQD�'HSDUWPHQW�RI�+HDOWK� 2IILFH�RI�3XEOLF�+HDOWK /$�:,&�9� QGRU�$SSOLFDWLRQ��5HY��10�������

Page 6: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

3DUW�����%$1.,1*�,1)250$7,21��,GHQWLI\�WKH�DFFRXQW�IRU�DOO�(%7�SD\PHQWV�RU�RWKHU�UHLPEXUVHPHQWV���9HULI\�\RXU�URXWLQJ�DQG�DFFRXQW�QXPEHU�ZLWK�\RXU�EDQN�RU�FRUSRUDWH�RIILFH�EHIRUH�FRPSOHWLQJ�WKLV�VHFWLRQ���

%DQN�1DPH�DQG�%UDQFK 1DPH�RQ�$FFRXQW 5RXWLQJ�1XPEHU $FFRXQW�1XPEHU

$GGUHVV &LW\ 6WDWH =,3 7HOHSKRQH

3DUW���� �6725(�6$/(6�,1)250$7,21��,Q�DFFRUGDQFH�ZLWK� IHGHUDO�:,&�UHJXODWLRQV��/RXLVLDQD¶V�:,&�3URJUDP� LV�UHTXLUHG� WR�HYDOXDWH�DQQXDO� IRRG�VDOHV�DQG� WKH�DPRXQW�RI�UHYHQXH� WKDW� LV� H[SHFWHG� WR�EH�GHULYHG� IURP�:,&�DQG�RWKHU�VRXUFHV���$OO�IRRG�VDOHV�LQIRUPDWLRQ�UHTXHVWHG�EHORZ�LV�EDVHG�RQ�WKH�VDOH�RI�61$3-HOLJLEOH�LWHPV�WR�DQ\�FXVWRPHU���6HH�WKH�DWWDFKHG�)RRG�6DOHV�)DFW�6KHHW�IRU�DGGLWLRQDO�LQIRUPDWLRQ�RQ�61$3-HOLJLEOH�LWHPV�

$���$QQXDO�*URVV�6DOHV��3OHDVH�SURYLGH�\HDUO\��QRW�PRQWKO\��DPRXQW�EHORZ�

3URYLGH�WKH�WRWDO�RI�DOO�IRRG�DQG�QRQ-IRRG�VDOHV�IRU�WKH�ODVW�WD[�\HDU���,I�WKH�VWRUH�ZDV�QRW�RSHQ�DOO�RI�WKH�ODVW�WD[�\HDU�RU�LI�WKH�VWRUH�KDV�QRW�EHHQ�RSHQ�IRU�DW�OHDVW����PRQWKV��SURYLGH�WKH�GDWHV�WKH�VWRUH�RSHUDWHG�GXULQJ�WKH�ODVW�WD[�\HDU�DQG�WKH�WRWDO�RI�DOO�IRRG�DQG�QRQ-IRRG�VDOHV�GXULQJ�WKDW�SHULRG��&KHFN�RQH��

���)XOO�<HDU������3DUW�<HDU��IURP���00�<<�����������������������������WR���00�<<������������������������������7RWDO�6DOHV����BBBBBBBBBBBBB

%���$QQXDO�)RRG�6DOHV�5HYHQXH��3OHDVH�SURYLGH�WKH�DSSURSULDWH�LQIRUPDWLRQ�EHORZ��$QVZHU�HLWKHU���RU���� ������,I�WKH�VWRUH�KDV�EHHQ�LQ�EXVLQHVV�IRU����PRQWKV�RU�PRUH��OLVW�WKH�$QQXDO�)RRG�6DOHV�5HYHQXH�IURP�WKH�SUHYLRXV�WD[�

\HDU�����BBBBBBBBBBBBBBBBBBBB���$WWDFK�\RXU�3DULVK�6DOHV�7D[�IRUPV�IURP�WKH�PRVW�UHFHQW�TXDUWHU�

25

�����,I�WKH�VWRUH�KDV�EHHQ�LQ�EXVLQHVV�IRU�OHVV�WKDQ����PRQWKV�DW�WKH�WLPH�RI�DSSOLFDWLRQ��SURYLGH�WKH $QWLFLSDWHG�$QQXDO�)RRG�6DOHV�5HYHQXH�����BBBBBBBBBBBBBBBBBBB��$WWDFK�DOO�DYDLODEOH�3DULVK�6DOHV�7D[�IRUPV�

&���6DOHV�7UDQVDFWLRQ�,QIRUPDWLRQ� ���'R�\RX�H[SHFW�WKH�VWRUH¶V�:,&�VDOHV�WR�EH�PRUH�WKDQ�����RI�LWV�DQQXDO�IRRG�VDOHV�UHYHQXH"�� ����<HV�� �������1R

���3URYLGH�DQWLFLSDWHG�DQQXDO�IRRG�VDOHV�UHYHQXH�E\�W\SH�RI�SD\PHQW���61$3���������������:,&���������������&DVK�FKHFN�������������&UHGLW����������

���,I�WKH�VWRUH�LV�QRW�FXUUHQWO\�RSHQ��GR�\RX�QHHG�:,&�DXWKRUL]DWLRQ�LQ�RUGHU�IRU�WKH�VWRUH�WR�RSHQ" ����<HV�� �������1R���������1�$

���,I�:,&�DXWKRUL]HG�GXULQJ�WKH�SDVW���PRQWKV��GLG�WKH�VWRUH�SURFHVV�DW�OHDVW����:,&�WUDQVDFWLRQV�HDFK�PRQWK" ����<HV�� �������1R���������1�$

���,I�QRW�:,&�DXWKRUL]HG�GXULQJ�WKH�SDVW���PRQWKV��GR�\RX�H[SHFW�WKH�VWRUH�WR�SURFHVV�DW�OHDVW����:,&�WUDQVDFWLRQV�SHU�PRQWK"�� ����<HV�� �������1R���������1�$

3DJH���RI�� /RXLVLDQD�'HSDUWPHQW�RI�+HDOWK� 2IILFH�RI�3XEOLF�+HDOWK /$�:,&�9� QGRU�$SSOLFDWLRQ��5HY��10�������

����K��)XOO-/LQH�*URFHU\�6WRUH��D�VWRUH�WKDW�FDUULHV�WKH�IROORZLQJ�LWHPV��· ��YDULHWLHV�RI�FHUHDO�ZLWK���RU�PRUH�XQLWV�RI�HDFK�YDULHW\�· ��YDULHWLHV�RI�EUHDG�RU�WRUWLOODV�ZLWK���RU�PRUH�XQLWV�RI�HDFK�YDULHW\�· ��YDULHWLHV�RI�IUHVK�IUXLWV�ZLWK�DW�OHDVW���XQLWV�RI�HDFK�YDULHW\�· ��YDULHWLHV�RI�IUHVK�YHJHWDEOHV�ZLWK�DW�OHDVW���XQLWV�RI�HDFK�YDULHW\�· ��YDULHWLHV�RI�IUHVK�RU�IUR]HQ�PHDW��SRXOWU\�RU�ILVK�ZLWK�DW�OHDVW���XQLWV�RI�HDFK�YDULHW\�· ��YDULHWLHV�RI�ULFH�ZLWK���RU�PRUH�XQLWV�RI�HDFK�YDULHW\�

������������'RHV�\RXU�VWRUH�FDUU\�WKH�DERYH�OLVWHG�LWHPV�LQ�WKH�YDULHWLHV�DQG�TXDQWLWLHV�OLVWHG"�������<HV�� �������1R

������������$UH�WKH�DERYH-OLVWHG�LWHPV�RQ�GLVSOD\�DQG�DYDLODEOH�IRU�UHWDLO�VDOH�GXULQJ�DOO�KRXUV�WKH�VWRUH�LV�RSHQ"�������<HV�� �������1R

3DUW�����6725(�23(5$7,21�6�,1�)250$7,�21��&RQWLQXHG�

Page 7: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

'��6XSSOHPHQWDO�1XWULWLRQ�$VVLVWDQFH�3URJUDP��61$3��$XWKRUL]DWLRQ�,QIRUPDWLRQ

���,V�WKH�VWRUH�DXWKRUL]HG�WR�SDUWLFLSDWH�LQ�61$3"� ����<HV�� �������1R ���61$3�$XWKRUL]DWLRQ�1XPEHU���BBBBBBBBBBBBBBBBBBBBBBB ���,I�QRW�FXUUHQWO\�61$3�DXWKRUL]HG��KDYH�\RX�VXEPLWWHG�DQ�DSSOLFDWLRQ�IRU�61$3�DXWKRUL]DWLRQ"��� ����<HV�� �������1R

$XWKRUL]DWLRQ�3HQGLQJ�'DWH��PP�GG�\\\\�����BBBB��BBBB���BBBBB 1RWH��7R�EHFRPH�DQ�$XWKRUL]HG�:,&�9HQGRU��WKH�DSSOLFDQW�PXVW�EH�FXUUHQWO\�SDUWLFLSDWLQJ�LQ�WKH�86'$�6XSSOHPHQWDO�1XWULWLRQ�$VVLVWDQFH�3URJUDP��61$3��

�3DUW�����6725(�6$/(6�,1�)250$7,�21��&RQWLQXHG�

3DUW� ��� ),1(6�� ',648$/,),&$7,216� $1'� &219,&7,216�

���$��+DYH� DQ\� RI� WKH� RZQHUV��RIILFHUV�RU�PDQDJHUV�

��������������%HHQ�RU�HPSOR\�DQ\�PDQDJHPHQW�SHUVRQQHO��LQFOXGLQJ�RZQHUV�DQG�FR-RZQHUV��WKDW�KDYH�EHHQ�

���D���'LVTXDOLILHG�RU�ILQHG�DVVHVVHG�D�FLYLO�PRQH\�SHQDOW\��&03��E\�61$3��:,&�RU�DQ\�RWKHU�86'$�IRRG�SURJUDP�LQ�/RXLVLDQD�RU�LQ�DQ\�RWKHU�VWDWH�LQ�WKH�SDVW�\HDU"

�������<HV��61$3��������������<HV��:,&��������������<HV��2WKHU��������������1R

���E���)RUPHUO\�HPSOR\HG�E\�D�9HQGRU�WKDW�ZDV�GLVTXDOLILHG�IURP�DQ\�86'$�IRRG�SURJUDP�LQ�WKH�SDVW�\HDU"

����������<HV��86'$�)RRG�3URJUDP��BBBBBBBBBBBBBBBBBBB����������1R

���������������%HHQ�GHQLHG�RU�WHUPLQDWHG�IURP�:,&�DXWKRUL]DWLRQ�ZLWKLQ�WKH�SDVW�\HDU"

�����������

����������<HV���������1R

$FFUXHG�DQ\�XQVDWLVILHG�XQSDLG�ILQHV��L�H���UHSD\PHQWV��&LYLO�0RQH\�3HQDOWLHV�>&03V@��IRUIHLWXUHV��HQIRUFHPHQW �SHQDOWLHV��RZHG�WR�61$3�RU�WKH�:,&�3URJUDP"

��������������������������<HV��61$3�LV�XQVDWLVILHG�XQSDLG�����������������<HV��:,&�LV�XQVDWLVILHG�XQSDLG�����������������1R

,I�\RX�DQVZHUHG�<(6�WR�������RU����DERYH��IRU�HDFK�DFWLRQ��SURYLGH�GHWDLOV�RQ�D�VHSDUDWH�SDJH�LGHQWLI\LQJ�WKH�VWDWH�DQG�3URJUDP��:,&��61$3�RU�RWKHU��LQ�ZKLFK�WKH�DFWLRQ�RFFXUUHG��WKH�W\SH�RI��GLVTXDOLILFDWLRQ��ILQH��&03��WHUPLQDWLRQ��DSSOLFDWLRQ�GHQLDO���GHVFULSWLRQ��DQG�GDWH�RI�WKH�DFWLRQ�

�����������&XUUHQWO\�FKDUJHG�ZLWK�RU�KDYH�HYHU�EHHQ�FRQYLFWHG�RI�D�IHORQ\��IHGHUDO��VWDWH�RU�ORFDO�WD[�YLRODWLRQV��RU�KDG�D�FLYLO� MXGJPHQW��LQFOXGLQJ�WD[�ZDUUDQWV��HQWHUHG�DJDLQVW�WKHP�ZLWKLQ�WKH�SDVW�VL[�\HDUV"�����������<HV���������1R

������������� ��%HHQ�RU�HPSOR\�DQ\�PDQDJHPHQW�SHUVRQQHO��LQFOXGLQJ�RZQHUV�DQG�FR-RZQHUV��WKDW�KDYH�EHHQ�IRUPHUO\�

emSOR\HG�E\�D�9HQGRU�WKDW�ZDV�

���D���&RQYLFWHG�RI�DQ\�IHORQ\�ZLWKLQ�WKH�SDVW�VL[�\HDUV"�����������<HV���������1R

���E���&RQYLFWHG�RI�DQ\�IHGHUDO��VWDWH��RU�ORFDO�WD[�YLRODWLRQV�ZLWKLQ�SDVW�VL[�\HDUV"����������<HV���������1R

,I�\RX�DQVZHUHG�<(6�WR�DQ\�SDUW�RI���RU���DERYH��IRU�HDFK�DFWLRQ�RU�FRQYLFWLRQ��SURYLGH�WKH�DSSURSULDWH�LQIRUPDWLRQ�EHORZ��,I�PRUH�VSDFH�LV�QHHGHG��SOHDVH�FRPSOHWH�RQ�D�VHSDUDWH�SDJH�DQG�DWWDFK�LW�WR�WKLV�DSSOLFDWLRQ�

3HUVRQ¶V�1DPH�DQG '2%�

(If Applicable)

6WRUH�%XVLQHVV�1DPH��,I�$SSOLFDEOH�

'HVFULSWLRQ�RI�$FWLRQ��&KDUJHG�&RQYLFWHG�LQFOXGLQJ�D�GHVFULSWLRQ�RI�

WKH�RIIHQVH��SHQDOW\� 'DWH &LW\ 6WDWH

3DJH���RI�� /RXLVLDQD�'HSDUWPHQW�RI�+HDOWK� 2IILFH�RI�3XEOLF�+HDOWK /$�:,&�9� QGRU�$SSOLFDWLRQ��5HY��10�������

Page 8: Louisiana WIC Vendor Initial Application Resources and ... · ☐ The same person signed both the Vendor Application and the Vendor Agreement ☐ The person signing the Application

3DUW����6,*1$785(6��&21),50$7,216�$1'�$)),50$7,216��&RPSOHWH�DSSOLFDWLRQ�PXVW�KDYH�DOO�UHTXLUHG�QDPHV�DQG�VLJQDWXUHV��DQG�PXVW�EH�QRWDUL]HG���,I�DQ\�RI�WKHVH�DUH�PLVVLQJ��WKH�DSSOLFDWLRQ�ZLOO�QRW�EH�FRQVLGHUHG�FRP�SOHWH�DQG�ZLOO�EH�UHWXUQHG�WR�DSSOLFDQW�

$IILGDYLW�RI�$SSOLFDQW��0XVW�EH�FRPSOHWHG�E\�WKH�VWRUH�RZQHU��SDUWQHU��PHPEHU�PDQDJHU��FRUSRUDWH�RIILFHU�RU�RWKHU�LQGLYLG�XDO�ZKR�KDV�DXWKRUL]DWLRQ�WR�VLJQ�RQ�EHKDOI�RI�YHQGRU��(QWLWLHV�RWKHU�WKDQ�VROH�SURSULHWRUVKLSV�PXVW�SURYLGH�SURRI�WKDW�WKH�LQGLYLGXDO����VLJQLQJ�WKLV�DSSOLFDWLRQ�KDV�WKH�DXWKRULW\�WR�FRQWUDFW�RQ�EHKDOI�RI�WKH�RZQHU�DSSOLFDQW�XQOHVV�VXFK�DXWKRULW\�LV�FOHDUO\�LQGLFDWHG�RQ�WKH�/RXLVLDQD�6HFUHWDU\�RI�6WDWH�ZHEVLWH��

�� ,�KDYH�OHJDO�DXWKRULW\�WR�DSSO\�IRU�DQG�VLJQ�WKLV�DSSOLFDWLRQ�VHHNLQJ�DXWKRUL]DWLRQ�IRU�WKH�YHQGRU�DSSOLFDQW�WR�SDUWLF�LSDWH�LQ�/RXLVLDQD¶V�:,&�3URJUDP�

�� ,�KDYH�UHDG�WKH�DSSOLFDWLRQ��9HQGRU�$JUHHPHQW��9HQGRU�*XLGH�DQG�)RRG�6DOHV�)DFW�6KHHW�SURYLGHG�WR�PH��,I�DX�WKRUL]HG�� ,� DJUHH� WR�FRPSO\�ZLWK� WKH� UHTXLUHPHQWV� VHW� IRUWK� LQ� WKH�DSSOLFDWLRQ��DJUHHPHQW��9HQGRU�*XLGH�DQG�DOO�IHGHUDO�DQG�VWDWH�SURJUDP�UHTXLUHPHQWV�DQG�UHJXODWLRQV��DQG�ZLWK�DQ\�FKDQJHV�WR�WKH�3URJUDP�UHTXLUHPHQWV�RU�UHJ�XODWLRQV� PDGH� GXULQJ� WKH� DJUHHPHQW� SHULRG�� � )HGHUDO� UHJXODWLRQV� JRYHUQLQJ� WKH�:,&� 3URJUDP� FDQ� EH� IRXQG� DW�KWWS���ZZZ�IQV�XVGD�JRY�ZLF�ZLF-ODZV-DQG-UHJXODWLRQV�

�� ,�DVVHUW� WKDW�DOO� WKH� VWDWHPHQWV� LQ� WKLV�DSSOLFDWLRQ�DUH� WUXH�� ,�XQGHUVWDQG� WKDW� IDOVH� VWDWHPHQWV�PDGH� LQ�FRQQHFWLRQ�ZLWK�P\�DSSOLFDWLRQ�IRU�DXWKRUL]DWLRQ�ZLOO�UHVXOW�LQ�WKH�GHQLDO�RI�DXWKRUL]DWLRQ�WR�SDUWLFLSDWH�LQ�WKH�:,&�3URJUDP�RU�UHVFLVVLRQ�RI�WKH�DXWKRUL]DWLRQ�VKRXOG�WKH�LQIRUPDWLRQ�EH�IRXQG�WR�EH�IDOVH�DIWHU�WKH�VWRUH�KDV�EHHQ�DXWKRUL]HG�

�� ,�XQGHUVWDQG�WKDW�WKLV�LV�RQO\�DQ�DSSOLFDWLRQ�IRU�DXWKRUL]DWLRQ��DQG�WKDW�12�:,&�WUDQVDFWLRQV�PD\�EH�DFFHSWHG�XQWLO�DQG�XQOHVV�WKH�/RXLVLDQD�:,&�3URJUDP�QRWLILHV�PH�LQ�ZULWLQJ�WKDW�:,&�YHQGRU�DXWKRUL]DWLRQ�KDV�EHHQ�JUDQWHG�

�� 7KLV�$SSOLFDWLRQ�FRQVLVWV�RI�WKLV�SDJH�DQG�VL[�SUHYLRXV�SDJHV�DOO�EHDULQJ�D�UHYLVLRQ�GDWH�RI�10������

������BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB�������������������������������BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB ������)XOO�/HJDO�1DPH�RI�,QGLYLGXDO�$XWKRUL]HG����������������������������������������������������������������������7LWOH��35,17�RU�7<3(� ������WR�6LJQ�RQ�%HKDOI�RI�9HQGRU��35,17�25�7<3(�

�����BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB���������������������������������BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB �����6LJQDWXUH�RI�,QGLYLGXDO�$XWKRUL]HG�WR�6LJQ�RQ�%HKDOI�RI�9HQGRU �����������������������������'DWH�6LJQHG��PP�GG�\\\\�

3DUW����127$5<�38%/,&��8QOHVV�WKH�LQGLYLGXDO�LV�SHUVRQDOO\�NQRZQ�WR�WKH�1RWDU\�3XEOLF��WKH�LQGLYLGXDO�PXVW�SURYLGH�WZR�IRUPV�RI�LGHQWLILFDWLRQ�WR�WKH�1RWDU\�3XEOLF���2QH�PXVW�EH�D�GULYHU¶V�OLFHQVH��SDVVSRUW��RU�/RXLVLDQD�VWDWH�LGHQWLILFDWLRQ�FDUG��

6ZRUQ�WR�DQG�VXEVFULEHG�EHIRUH�PH�WKLV�BBBBBBBBBBBBBBBBBBB�GD\�RI�BBBBBBBBBBBBBBBB���

��BBBBBBB�LQ�WKH�VWDWH�RI�BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB��

BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

6LJQDWXUH�–�1RWDU\�3XEOLF

&KHFN�RQH��

��0\�FRPPLVVLRQ�H[SLUHV�RQ��PP�GG�\\\\���BBB�BBBB�BBBBB

��0\�FRPPLVVLRQ�LV�IRU�OLIH��

�&&/y�^��>�,�Z�

7KLV�LQVWLWXWLRQ�LV�DQ�HTXDO�RSSRUWXQLW\�SURYLGHU�

3DJH���RI�� /RXLVLDQD�'HSDUWPHQW�RI�+HDOWK�� 2IILFH�RI�3XEOLF�+HDOWK /$�:,&�9� QGRU�$SSOLFDWLRQ��5HY��10�������