Retailer Cash Register (POS) System Questionnaire

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Tuesday, September 07, 2010

..:: For Retailers » Retailer Cash Register (POS) System Questionnaire ::..

Questionnaire Info

Retailers may complete the form in one of three ways:

Complete the online form on this page. If you are a retailer with multiple stores, please use the form for stores with common information, noting the relevant WIC merchant IDs where indicated. If you have multiple stores, it is generally not necessary to complete a form for each, as long as we know which merchant IDs the information applies to.
Download the MS Word version of the form, complete, and return via e-mail to the correct agency email addresses listed at the bottom of the page.
Download the PDF version of the form, complete and mail to the correct agency address listed at the bottom of the page.

Please complete the questionnaire even if the systems you have are listed on the Solution Integration & Certification Status page.

Retailer Cash Register (POS) System Questionnaire - Online Form

Retail Vendor Information
Retail Vendor Name:	*
Address Line 1:	*
Address Line 2:
City:	*
State:	*
ZIP Code:	*
Web Site:
WIC Agency / Health Department Info.
WIC Agency (State or ITO; i.e. KY):	*
WIC Vendor Number:	*
WIC Agency Health Department:	*
Add'l WIC Vendor #'s with this Contact Info.:
Retailer Vendor Contact Information
Retailer's WIC Contact Name (Owner and/or Corp):	*
... Email:
... Phone #:	*
... Fax #:
Retailer's Point Of Sale/Info. Technology Contact:	*
.... Email:	*
.... Phone #:	*
.... Fax #:	*
POS/Cash Register System Information
POS/Cash Register System Brand:	*
... website:
Software Program Name:	*
... Version:	*
Supports Scanning:	*
POS Electronic Payment System (EPS):
.... Version:
Electronic Payment Processor (ie First Data; 5/3):
EPS Link Name (ie Buypass; MPS; Concorde):
Store has internet connection:	*
Point Of Sale Vendor Contact Info
Point Of Sale Supplier / Distributor:	*
..... Contact Name:	*
..... Email:	*
..... Phone #:	*
..... Fax #:	*
..... website:	*
Please include any additional information:
Security Code:		Enter the code shown above in the box below

* required

Retailer Cash Register (POS) System Questionnaire - Email or Print and Return

Title	Category	Modified Date		Description
Retailer Cash Register (POS) System Questionnaire (Word)		10/12/2009	Download	Retailer POS System Questionnaire in MS Word format for download, complete, and return via email.
Retailer Cash Register (POS) System Questionnaire (PDF)		10/12/2009	Download	Retailer POS System Questionnaire in PDF format for download, complete, and return via regular mail.

Questionnaire Mailing Addresses

When returning the questionnaire via regular mail, please use the following addresses for the indicated WIC agency.

Kentucky WIC

Return via email to wicdirectky@wicdirectsystem.com

Return via U.S.Mail to:

Cabinet for Health and Family Services
Department for Public Health
Nutrition Services Branch
275 East Main Street, HS2W-D
Frankfort, Kentucky 40621
Attention: Vendor Management Section