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.

Once you have completed and printed the form please sign and send the form to this address: Freepost RTJL-CSJZ-GRRA, HSRU, Barberton House, Farndon Road, MARKET HARBOROUGH, LE16 9NR

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 line 1*  
Trading address line 2
Trading address line 3
Trading address town
Trading address postcode*  

Tick this box if you have recently taken over this business

If so, then please provide the previous account number

Payment address if different from above.
Payment name
Payment address line 1
Payment address line 2
Payment address line 3
Payment address town
Payment address 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
Frozen Foods

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

I confirm that I have read and understand the terms and conditions.



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