N. INFANT CEREAL: Highest price. 8 or 16 oz. containers. No added fruit or quinoa. No organic. Oatmeal Rice M. JUICE CONCENTRATE: Highest price. Frozen or Multigrain shelf stable. 11.5 or 12 oz. containers only. No organic. Barley Brand Price Other Orange Apple O. INFANT FOOD: Highest price. No organic. Grape Grapefruit Price Pineapple 4 oz. Jar of Fruit Other with yellow and/or Veggie tab 8 oz. 2-Pack of Old Orchard with and/or Veggie green tab 2.5 oz. Jar of Meat Dole (any flavor) Welch’s shelf stable (any flavor) P. INFANT FORMULA: *Indicates required formulas for all stores, even without pharmacies. Is your store also a pharmacy? Yes No ☐ ☐ If yes, pharmacies must provide prices for all formulas listed on this page and the next page or this application will not be approved. If your store does not have a pharmacy, then please provide prices of the formulas that are regularly stocked. Can you obtain any of the items on the WIC formulary list page 1-3 located at within 2 working days? Who is the WIC contact for special order formula at your store? Name Title Number Email
M. JUICE CONCENTRATE: Highest price. Frozen or shelf stable. 11.5 or 12 oz. containers only. No organic. Brand Price Orange Apple Grape Grapefruit Pineapple Other with yellow tab Old Orchard with green tab Dole (any flavor) Welch’s shelf stable (any flavor) N. INFANT CEREAL: Highest price. 8 or 16 oz. containers. No added fruit or quinoa. No organic. Oatmeal Rice Multigrain Barley Other O. INFANT FOOD: Highest price. No organic. Price 4 oz. Jar of Fruit and/or Veggie 8 oz. 2-Pack of and/or Veggie 2.5 oz. Jar of Meat P. INFANT FORMULA: *Indicates required formulas for all stores, even without pharmacies. Is your store also a pharmacy? ☐ Yes ☐ No If yes, pharmacies must provide prices for all formulas listed on this page and the next page or this application will not be approved. If your store does not have a pharmacy, then please provide prices of the formulas that are regularly stocked. Can you obtain any of the items on the WIC formulary list page 1-3 located at within 2 working days? Who is the WIC contact for special order formula at your store? Name Title Number Email