Healthy Start Supplier Application Form

If you would like to complete the on-line application form please be aware that you will need to have a printer connected to your PC.

This form is in a PDF format so you will also need to have an Adobe Acrobat Reader (external link)

Once you have completed and printed the form please sign and send the form to this address: HSRU, Freepost (LE6004), Market Harborough, Leicestershire, LE16 7BR

If you have any problems or prefer to request a form to be sent to you please contact the HSRU on 0844 991 2222

Trading name*
Trading address*
Trade street
Trade Village
Trade Town
Postcode*

Tick this box if you have recently taken over this business

Payment address if different from above.
Payment name
Payment address
Pay Street
Pay Village
Pay Town
Postcode
Tick this box if this is a coupon clearing house

Contact name
Telephone
Email address
VAT Reg No

Please provide bank details of your business
Sort code*
Account number*
Account name*

Please indicate which of the following supplier categories best describe your business*
Food Cooperative or Box Scheme
Independent chemist
Independent retailer
Market Trader
Milk roundsman
Multiple chemist
Multiple retailer (non-franchised)
Multiple retailer (franchised)
Wholesaler
How many outlets are you registering for?
Average number of tills per outlet
Which of the following Healthy Start foods do you sell? (Please tick all appropriate boxes)*
Liquid cow's milk
Fresh fruit
Fresh vegetables
Infant formula milk
Would you like your business to appear on the list of participating Suppliers?*
Yes
No
Have you ever had an application to join the Welfare Food or Healthy Start schemes denied?*
Yes
No
Have you ever been disqualified from the Welfare Food or Healthy Start schemes?*
Yes
No

After clicking on submit you will be presented with a form (please note this could take a few minutes depending on your connection speed), please print and sign this and return it to the address given.