Texas WIC Product Submission - Apply For Account

Apply For Company Account

Tax Identification Number

(xx-xxxxxxx or xxx-xx-xxxx)

Company Name

Submitter Type

If you are a Manufacturer or Brand Owner (whether managing products directly or using a broker or agent), please select 'Manufacturer or Brand Owner' from the list below

If you are a Broker or Agent (representative for another company), please select 'Broker or Agent' from the list below

Submitter Type List

Primary Contact

Position

First Name

Last Name

Phone

Phone Extension

Mailing Address

Address 1

Address 2

City

State

Zip