| 1 |
District
health office and telephone number |
| 2 |
Your vendor's
name, address and telephone number |
| 3 |
Your name
and address or delivery directions |
| 4 |
The names
of WIC participants in your household |
| 5 |
The month
you need to recertify your WIC |
| 6 |
The month
that the POD is for |
| 7 |
The total
amount of food you will receive each month |
| 8 |
The dates
that your food will be delivered |
| 9 |
Write
in any missing food items |
| 10 |
Check
YES or NO each month to show whether you received all your WIC food |
| 11 |
Sign the
form at the end of each month |
