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VENDOR AGREEMENT WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC) Vendor Number: SNAP Number: County: Name of Vendor: Address: City: State: Zip Code: Email Address: Telephone Number: The undersigned representative for the Vendor specified on this Agreement, do hereby acknowledge that I have read the WV WIC Vendor Agreement and agree to the requirements as set forth by the WV WIC Program and this Vendor Agreement. I acknowledge that I or my designated representative(s) has attended Vendor Authorization Training. I have had sufficient opportunity to review and consider this Agreement, consult with legal counsel, and ask questions of WV WIC Program representatives regarding such requirements. I acknowledge that I have reviewed the WV WIC Vendor Handbook, Vendor Sanction Policy, and Vendor Sanction Listing and that I fully understand that violations of WV WIC Policy by employees, representatives, or agents of the above-named Vendor will result in disqualification from the WV WIC Program. Vendor Representative: _______________________________________________ ___________________________ Signature of Vendor Representative Date WV WIC Representative: _______________________________________________ _________________________ Signature of WV WIC Program Representative Date Page 11 of 12