Instructions
Complete the following information and click Submit. In addition to this form, you will need to fax or email the following items to:
Kari Broughton at 217/524-6124 or kbrought@isbe.net : After review, your organization will then be assigned an Agreement Number and contacted regarding an ISBE Web-based Illinois Nutrition System (WINS) administrative account.
Sponsor
DUNS #: (9 digit number, NOT your FEIN/TIN)
Sponsor Name: (As it appears in tax documents)
Street 1:
Street 2:
City:
State:
Zip:
County:
Phone: x
Cell:
Fax: x
Sponsor Entity Type
FEIN
Public/Private
Tax Exempt Status
Authorized Rep
"Authorized Representative" is the person who is legally and administratively responsible for your institution.
First:
Middle:
Last:
Title:
Phone: x
Cell:
Fax: x
E-mail:
 








Contact
A "Contact" only provides someone who ISBE may contact when the "Authorized Representative" is not available.
First:
Middle:
Last:
Title:
Phone: x
Cell:
Fax x
E-mail:
Food Service
Total number of sites administered New sponsors can initially operate two sites their first year. Contact SFSP staff with any questions @ (800)545-7892.
Date first site opens
Date last site closes
Method of meal preparation
Meal Preparation Location
Submit
By clicking the Submit button, you certify that all information presented in this form is true and correct to the best of your knowledge. If you agree to these terms, please press Submit.