#0693-0006-MBNQA-AwardApplication&Checklist-WithTrackedChanges

Update to 2017

website

This document contains the Application Form and checklist for the
2013 Malcolm Baldrige National Quality Award. Before filling out
the form, please read the Application Content and Format guidelines
on our Web site (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
Notwithstanding any other provision 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 Paperwork Reduction Act, unless that collection
of information displays a currently valid OMBUse
Control
Number.notwithstanding
updated
The reason for collecting this information is tostatement
allow organizations to apply for the Malcolm Baldrige National Quality Award
(award). The information obtained will assist in determining the award recipients. Responses to the collection of information are
required for organizations to be considered for the award. Confidentiality of the submitted information is covered under the Freedom
of Information Act to the extent possible under the law.
The public reporting burden for this collection is estimated to average 100 hours for the initial response of the first-time applicant (this
includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the relevant data, and
completing and reviewing the collection of information). As the organization reapplies for the award in future years, this burden may
change, in either direction, based on the feedback the respondent gains from its first application.

Robert Fangmeyer

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to
Dr. Harry Hertz, Director
Baldrige Performance Excellence Program
National Institute of Standards and Technology
Administration Building, Room A600
100 Bureau Drive, Stop 1020
Gaithersburg, MD 20899-1020
and to
Office of Information and Regulatory Affairs
Office of Management and Budget
Washington, DC 20503

Add:
OMB Clearance #0693-0006
Expiration Date: May 31, 2016

2017

May 31, 2016

2013 Award Application Form

OMB Clearance #0693-0006
Expiration Date: March 13, 2013

Malcolm Baldrige National Quality Award
1. Your Organization

Page A-1 of 2

4. Alternate Official Contact Point
Mr.

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

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,
word not
facilitate an open and unbiased examination, and
needed
pay reasonable costs associated with the site visit
(see the Award Process Fees page on our Web site
[http://www.nist.gov/baldrige/enter/award_fees.cfm].)

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

3. Official Contact Point

Ethics Statement and Signature of
Highest-Ranking Official

Designate a person with in-depth knowledge of the
organization, a good understanding of the application, and
I state and attest that
the authority to answer inquiries and arrange a site visit, if
necessary. Contact between the Baldrige Program and your (1) I have reviewed the information provided by my
organization in this award application package.
organization is limited to this individual and the alternate
official contact point. If the official contact point changes
(2) To the best of my knowledge,
during the application process, please inform the program.
 this package contains no untrue statement of a
material fact and
Mr. Mrs. Ms. Dr.
 omits no material fact that I am legally permitted to
Name
disclose and that affects my organization’s ethical
Title
and legal practices. This includes but is not limited
Same as above
to sanctions and ethical breaches.
Mailing
address
Overnight
mailing
address
Telephone
Fax
E-mail

Same as above (Do not use a P.O.
box number.)

Signature
Mr.

Date
Mrs.

Ms.

Printed name
Job title
Applicant name
Mailing address

Same as above

Telephone
Fax

2017 due dates TBD

Dr.

Award package due May 14, 2013 (April 30 on CD only)

2017

2013 Award Application Form

Add to header, above page
number, OMB Clearance
#0693-0006

the
6. Fees
Indicate the amounts enclosed. (See Award Process Fees page on our Web site
[http://www.nist.gov/baldrige/enter/award_fees.cfm].)
Application fee
CD processing fee ($1,250, if applicable)

Page A-2 of 2

website is one word
and lowercase now
per change in
Baldrige style
guidelines based
on Chicago style
guidelines

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 [email protected]). 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 May 7, please send the package via an overnight delivery service.

due date TBD

If you are unable to respond to any item, call (877) 237-9064, option 3,
before submitting your award application package.

25. We now will ask for 25 so that
Baldrige will not incur additional
copying costs.
1. Award Application Package
I have included 15 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 Web site at [http://www.nist.gov/baldrige/enter/upload/2013-ApplicationContent-and-Format.pdf].)
3. Application

25

The 15 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 Web site at [http://www.nist.gov/baldrige/enter/upload/2013-Application-Content-andFormat.pdf]:

website

URL has changed
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 datestamped, 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 datestamped chart(s) or (2) an electronic version that is not date-stamped, plus one paper copy of the date-stamped
2017
chart(s)
page A-1 of the 2013 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 14, 2013 (on paper and CD), or April 30, 2013
(on CD only). If I am submitting it after May 7, I am sending the package via an overnight delivery service.
I have included proof of the mailing date. (See page A-2.)
All 2017 due dates
I am sending the complete award application package to
Malcolm Baldrige National Quality Award
c/o ASQ—Baldrige Award Administration
600 North Plankinton Avenue
Award package due May 14, 2013 (April 30 on CD only)

TBD

2013 Award Application Form

Add to header, above page
number, OMB Clearance
#0693-0006

Milwaukee, WI 53203
(414) 298-8789, ext. 7205

2017

If you are unable to respond to any item, call (877) 237-9064, option 3,
before submitting your award application package.

Page A-2 of 2