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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15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

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