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2. Items Available for Order
4. WIC Approved Food List Quantity
5. WIC Door Decal Quantity
7. Set of Shelf Labels Quantity
9. Person Completing This Order Form
11. Name*
12. Vendor Name*
14. Address*
16. City*
17. State*
18. Zip Code*
20. Phone Number*
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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