WIC Application

2. Name
   Last, First, MI
4. Family Size
   -- Select One --12345678 or more
5. Monthly Income*
   -- Select One --$0 to $2,455$2,456 to $3,097$3,098 to $4,379$4,380 to $5,021$5,022 to $5,554$5,555 to $6,303

   Please Select One
7. Address
   Current Physical Address
9. Mailing Address If Different From Above
11. City, CA , Zip
13. Preferred Method of Communication
    -- Select One --PhonePostal Servicee-mail

    Please Select One
14. Contact number or e-mail
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

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