Food Program Change in Provider Info

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Food Program Change in Provider Info

Complete this form regarding a change of address, email address, phone number, or name. Please fill out any fields that apply. If there are any changes to your child care certificate or license, such as the type of regulation, address, name change, capacity, age range of children cared for, hours of operation, and/or days of operation, you MUST submit a copy of your new certificate or license to the WECA Food Program or fax it to 866-222-9520.

Email *

Please enter the email address where you would like to receive the receipt of this form.

Your Six-Digit WECA CACFP Provider Number *

First Name *

Last Name *

Effective Date of Change *

New Name (First)

New Name (Last)

New Physical Address

New City

New State

New Zip Code

New Phone Number (including area code)

New Email Address

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