upc request
Michigan Department of Health and Human Services
WIC Division
Instructions: Complete the items in the Vendor Information area. Print or type information, and Fax to 517-335-9206. Questions should be directed to 800-942-1636 for Vendor Assistance. If fax is not available mail to Michigan Department of Health and Human Services (MDHHS), Lewis Cass Building – WIC, 320 South Walnut, Lansing, MI 48913. Telephone requests will not be allowed.
VENDOR INFORMATION
Vendor Name	Vendor WIC Number	Phone Number	Fax Number
Address	City	Zip Code
PRODUCT INFORMATION
Food Item: (Example: Milk, Cheese, Tuna, etc.)	Item Price	Package Size (oz)
Name of Manufacturer
Food Brand Name
UPC Code (include all numbers)
Food Description (Example: Flavor, Type, Added Ingredient, etc.)
Copy of UPC Code & Label of Food Item Sent (Please Check One) Yes No
Authorized Vendor (Please Print)
Authorized Vendor Signature	Date
STATE USE ONLY
Date Received	Received By	Date Reviewed	Reviewed By
Decision Approved Not Approved Review Pending
Reason
Date UPC Entered	Entered By	Category	Sub Category	Vendor Peer Group
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
This institution is an equal opportunity provider.