MBNQA Application & Checklist

This document contains the Application Form and checklist for the 2017 Malcolm Baldrige National Quality Award. Before filling out the form, please read the Application Content and Format guidelines on our website [http://www.nist.gov/baldrige/enter/format.cfm].

The form uses text fields (     ) that expand as you type. To enter text, place your cursor in the field, click to highlight the field, and begin typing. Use the Tab key to navigate to the next field.

Paperwork Reduction Act Statement

This collection of information contains Paperwork Reduction Act (PRA) requirements approved by the Office of Management and Budget (OMB). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the PRA unless that collection of information displays a currently valid OMB control number. Public reporting burden for this collection is estimated to be 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the National Institute of Standards and Technology, Attn: Robert Fangmeyer, Director Baldrige Program, robert.fangmeyer@nist.gov.

OMB Control No. 0693-0006

Expiration Date: 05/31/2016

1. Your Organization

Official name	     
Mailing address	     

2. Award Category and Criteria Used

a. Award category (Check one.)

Manufacturing

Service

Small business. The larger percentage of sales is in (check one) Manufacturing Service

Education

Health care

Nonprofit

b. Criteria used (Check one.)

Business/Nonprofit

Education

Health Care

3. Official Contact Point

Designate a person with in-depth knowledge of the organization, a good understanding of the application, and the authority to answer inquiries and arrange a site visit, if necessary. Contact between the Baldrige Program and your organization is limited to this individual and the alternate official contact point. If the official contact point changes during the application process, please inform the program.

Mr. Mrs. Ms. Dr.

Name	     
Title	     
Mailing address	Same as above      
Overnight mailing address	Same as above (Do not use a P.O. box number.)      
Telephone	     
Fax	     
E-mail	     

4. Alternate Official Contact Point

Mr. Mrs. Ms. Dr.

Name	     
Telephone	     
Fax	     
E-mail	     

5. Release and Ethics Statements

Release Statement

I understand that this application will be reviewed by members of the Board of Examiners.

If my organization is selected for a site visit, I agree that the organization will

• host the site visit,

• facilitate an open and unbiased examination, and

• pay reasonable costs associated with the site visit (see Award Process Fees on our website [http://
  www.nist.gov/baldrige/enter/award_fees.cfm]).

If selected to receive an award, my organization will share nonproprietary information on its successful performance excellence strategies with other U.S. organizations.

Ethics Statement and Signature of
Highest-Ranking Official

I state and attest that

1. I have reviewed the information provided by my organization in this award application package.

2. To the best of my knowledge,

• this package contains no untrue statement of a material fact and

• omits no material fact that I am legally permitted to disclose and that affects my organization’s ethical and legal practices. This includes but is not limited to sanctions and ethical breaches.

	     
Signature	Date

Mr. Mrs. Ms. Dr.

Printed name	     
Job title	     
Applicant name	     
Mailing address	Same as above      
Telephone	     
Fax	     

6. Fees

Indicate the amounts enclosed. (See the Award Process Fees page on our website [http://www.nist.gov/baldrige/enter/award_fees.cfm].)

Application fee	     
CD processing fee ($1,250, if applicable)	     
Supplemental section fee (if applicable)	     
Total	$ 0.00

Indicate your method of payment.

Check (enclosed) Money order (enclosed) Make payable to the Malcolm Baldrige National Quality Award.
ACH payment Wire transfer		Checking ABA routing number: 075-000-022 Checking account number: 182322730397
Before sending an ACH payment or wire transfer, notify the American Society for Quality (ASQ; [414] 298-8789, ext. 7205, or mbnqa@asq.org). Reference the Baldrige Award with your payment.
Visa MasterCard American Express
Card number	     		Authorized signature
Expiration date	     		Printed name	     
Card billing address	     		Today’s date	     

W-9 Request

If you require an IRS Form W-9 (Request for Taxpayer Identification Number and Certification), contact ASQ at (414) 298-8789, ext. 7205.

Note: Do not include this page (page A-2 of the Application Form) in your PDF file. Instead, submit one paper copy with your award application package.

7. Submission

Include proof of the mailing date. Send the package via

• a delivery service (e.g., Airborne Express, Federal Express, United Parcel Service, or United States Postal Service [USPS] Express Mail) that automatically records the mailing date or

• the USPS (other than Express Mail), and include a dated receipt from the post office.

If you submit your application on paper after May3, please send the package via an overnight delivery service.

1. Award Application Package

I have included 25 individually bound paper copies of my organization’s application (and any required supplemental sections) and a CD containing the application as a printable PDF file OR

I have included a CD only containing the application as a printable PDF file.

2. Format

The application meets all formatting requirements. (See the guidelines listed under “Format” in the Application Content and Format PDF file on our website at http://www.nist.gov/baldrige/enter/format.cfm.)

3. Application

The 25 paper copies of the application each contain (and/or the CD version contains) the following sections, as well as the labeled tabs or divider pages indicated in the guidelines listed under “Content” in the Application Content and Format PDF file on our website at http://www.nist.gov/baldrige/enter/format.cfm:

blank front cover

title page

Table of Contents

date-stamped copy of the Eligibility Certification Form received from ASQ or, on the CD, either (1) a scan of the date-stamped Eligibility Certification Form received from ASQ or (2) an electronic version that is not date-stamped, plus one paper copy of the date-stamped document

date-stamped copy of the organization chart(s) received from ASQ or, on the CD, either (1) a scan of the date-stamped chart(s) or (2) an electronic version that is not date-stamped, plus one paper copy of the date-stamped chart(s)

page A-1 of the 2017 Application Form

Glossary of Terms and Abbreviations

Organizational Profile

Responses Addressing All Criteria Items

blank back cover

4. Page A-2 of the Application Form

I have included one paper copy of page A-2.

5. Fees

I have indicated my method of payment for the application fee.

If paying by check or money order, I have made it payable to the Malcolm Baldrige National Quality Award and included it in the award application package.

If submitting the application on a CD only, I have included the $1,250 processing fee.

6. Submission

I am submitting the award application package no later than May 10, 2017(on paper and CD), or April 26, 2017(on CD only). If I am submitting it after May 3, I am sending the package via an overnight delivery service.

I have included proof of the mailing date. (See page A-2.)

I am sending the complete award application package to

Malcolm Baldrige National Quality Award
c/o ASQ—Baldrige Award Administration
600 North Plankinton Avenue
Milwaukee, WI 53203
(414) 298-8789, ext. 7205