MBNQA Eligibility Form and Award Application

This document contains the Application Form and checklist for the 2022 Malcolm Baldrige National Quality Award. Before filling out the form, please read the Application Content and Format guidelines on our website [https://www.nist.gov/baldrige/application-content-and-format].

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

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0693-0006. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 74 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, 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: 07/31/2022

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 this 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 (office and cell, if possible)	     
Fax	     
Email	     

4. Alternate Official Contact Point

☐ Mr.☐ Mrs.☐ Ms.☐ Dr.

Name	     
Telephone	     
Fax	     
Email	     

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, my organization will

• host the site visit,

• facilitate an open and unbiased examination, and

• pay reasonable costs associated with the site visit (see Baldrige Award Process Fees at https://www.nist.gov/baldrige/baldrige-award/award-process-fees/).

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	     
Email

6. Fees

Indicate the amounts enclosed. (See the Baldrige Award Process Fees page on our website [https://www.nist.gov/baldrige/baldrige-award/award-process-fees].)

Application fee	     
Total	$ 0.00

Indicate your method of payment.

☐Check ☐ Money order Official Name of Organization:       Mailing Address:      
To pay by check or money order, please make payable to the Malcolm Baldrige National Quality Award and include the name of the organization applying on the memo line. Include one printed copy of this page with your payment.
☐ ACH payment ☐ Wire transfer Checking ABA routing number: 041000124 Checking account number: 4245714835
Before sending an ACH payment or wire transfer, please notify the American Society for Quality by emailing: asqbaldrige@asq.org and gaustin@asq.org Please 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

Double-click on the PDF icon below to access ASQ’s W-9. Contact ASQ at (414) 765-7205 with questions.

Note: Do not include this page (page A-2 of the Application Form) in your 50-page PDF application file.

7. Submission

You must email asqbaldrige@asq.org to request a link to submit your application through NIST’s secure file transfer system.

1. Award Application Package

☐ I have included my organization’s application as a printable PDF file

2. Format

☐ The application meets all formatting requirements. (See Application Content and Format webpage and Details document)

3. Application

The application contains the following sections, as well as divider pages indicated in Application Content and Format webpage and Details document:

☐ title page

☐ Table of Contents

☐ page A-1 of the 2022 Application Form

☐ date-stamped copy of the Eligibility Certification Form received from ASQ

☐ date-stamped copy of the organization chart(s) received from ASQ

☐ Glossary of Terms and Abbreviations

☐ Organizational Profile

☐ Responses Addressing All Criteria Items

4. Page A-2 of the Application Form

☐ I have included one paper copy of page A-2 with my check or money order payment.

☐ I am paying by ACH payment or wire transfer and uploading page A-2 with my application package.

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 mailed it to

Malcolm Baldrige National Quality Award
c/o ASQ—Baldrige Award Administration
600 North Plankinton Avenue
Milwaukee, WI 53203
(414) 765-7205

*Remember to include the name of the organization applying on the memo line.

6. Submission

☐ I am requesting a link to NIST’s secure file transfer system from asqbaldrige@asq.org and submitting the award application package no later than May 2, 2022 (PDF file only).