WIC Local Agency Information WIC Local Agency’s Legal Federal Employers ID# Name DUNS # CFDA # Type of Organization Tribe Private Non-profit 10.557 Tribe/Agency Administrative Number and Street or PO Box Mailing Address City, State, Zip WIC Main Clinic Street Number and Street or intersection/description Address (provide description if no City, State, Zip street address is available) WIC Clinic Mailing Address Number and Street or PO Box (if different) City, State, Zip WIC Clinic UPS/Fed Ex Number and Street or intersection/description Shipping Address (if different) City, State, Zip Primary Contact Name (person responsible for functions) Email Phone Fax Certifying Signature Name (person who can legally bind the WIC local agency and Title certify the funding application) WIC Staffing Plan *Identify at least one person for the following positions: Breastfeeding Lead & Registered Dietitian
WIC Local Agency Information WIC Local Agency’s Legal Name Federal Employers ID# Type of Organization Tribe Private Non-profit DUNS # CFDA # 10.557 Tribe/Agency Administrative Mailing Address Number and Street or PO Box City, State, Zip WIC Main Clinic Street Address (provide description if no street address is available) Number and Street or intersection/description City, State, Zip WIC Clinic Mailing Address (if different) Number and Street or PO Box City, State, Zip WIC Clinic UPS/Fed Ex Shipping Address (if different) Number and Street or intersection/description City, State, Zip Primary Contact (person responsible for functions) Name Email Phone Fax Certifying Signature (person who can legally bind the WIC local agency and certify the funding application) Name Title WIC Staffing Plan *Identify at least one person for the following positions: Breastfeeding Lead & Registered Dietitian
FY2014reapplication.docx