Retailer Supply Request Form

Virginia WIC Program
Retailer Supply Request Form

  • Please enter the quantity for the items desired (1-99), complete the Contact Information, and select the “Submit” button.

  • Contact Information

  • MM slash DD slash YYYY

+Downloads are available online at:

Contact your assigned Vendor Liaison if this order is not received within two weeks.

*Additional supplies e.g. Door decals, lane signage, etc. can be ordered directly through the eWIC Processor.