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WIC APPLICATION

FIRST & LAST NAME:
CURRENT ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
BIRTHDAY (DAY/MONTH):
NUMBER OF PEOPLE IN YOUR FAMILY
HOUSEHOLD GROSS INCOME (BEFORE TAXES)
IS YOUR HOUSEHOLD INCOME BY?  
ARE YOU PREGNANT?  YES  NO
IF YES, WHEN IS YOUR DUE DATE? (DD/MM)
HAVE YOU HAD A BABY IN THE LAST 6 MONTHS?  YES  NO
ARE YOU BREASTFEEDING A BABY WHO IS LESS THAN ONE YEAR OF AGE?  YES  NO
PLEASE LIST THE NAME(S), SEX, AND BIRTHDATE(S) OF YOUR CHILDREN UNDER AGE 5.