WIC Material Request Form

First Name*

Required.

Last Name*

Required.

Email*

Required.

Phone Number*

Required.

Organization Name*

Required.

Mailing Address*

Required.

City*

Required.

Zip Code*

Required.

Interoffice mail code (if applicable)

For San Bernardino County offices

Please select your requested WIC item

Select language(s) needed*

English

Spanish

Other

Required.

Other language requested

If you selected "Other" language, please fill out language required other than English or Spanish.

Quantity requested in English

Quantity requested in Spanish

Quantity requested in other language