CT WIC Application

Certification Applying For:

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Phone *

Email *

Proof of Address: You must attach to this application two clearly legible evidence of you are a DC resident such as a copy of your driver's license, identification card, or utility bill.

DC ID & Proof of Residency

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload your DC ID and proof of residency.

Layout

Name of most recent school/ college/ university

Did you graduate?

Yes
No
GED

Dates you attended

Layout (copy)

Name of most recent school/ college/ university

Did you graduate?

Yes
No
GED

Dates you attended

Employment Status

Employer

Address/ Phone #

Job Title

Supervisor

Military Service

Branch

If other than honorable, explain:

Dates of service

Rank at discharge

Type of discharge

Signature *

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