Applying to Become An Authorized Retailer

A retailer that would like to accept food stamp benefits (EBT) must have a food stamp program permit. To have a food stamp program permit application package mailed to you, please complete this request form and choose submit. An application package will be mailed within one business day, and customers usually receive the application package within 3-4 business days. Applications are mailed Monday through Friday, excluding Federal holidays.

All fields marked with an asterisk (*) must be filled out.

	Number of Applications Requested	1 2 3 4 5 6 7 8 9 10+
	First Name *
	Last Name *
	Title
	Phone Number *
	Mailing Address *
	City *
	State *	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
	Zip Code (first 5 digits) *
	Zip + 4 (last 4 digits)
	Business Name *
	City of Business Location *
	County of Business Location *
	State of Business Location *	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
	Zip of Business Location *

  

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