Apply today! - WIC WIC for You

Please complete this form. A WIC representative will contact you soon. She or he will answer all your questions.

Your first name (required)*
Your last name (required)*
Phone number with area code (required)*
Please enter all 10 numbers:
xxx-xxx-xxxx
What kind of phone is this?
- A cell phone
- A landline
A second phone number with area code
Please enter all 10 numbers:
xxx-xxx-xxxx
What kind of phone is this?
- A cell phone
- A landline
Address
Your address City State ZIP Code
Email address
What is the best way to reach you?
- By cell phone
- By landline
What is the best time to reach you?
- 8:00 a.m. - noon (morning)
- noon - 4 p.m. (afternoon)
- 4 p.m. - 8 p.m. (evening)
Do you want to write a message?

Do you have questions about this form? Phone (310) 661-3080.