MBNQA Application & Checklist

This document contains the Application Form and checklist for the
2019 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-contentand-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
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 60 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,
[email protected].
OMB Control No. 0693-0006
Expiration Date: 06/30/2019

Privacy Act Statement

Authority: The National Institute of Standards and Technology Act, as amended, 15 U.S.C. 271 et seq. (which includes Title 15 U.S.C.
272) and section 12 of the Stevenson-Wydler Technology Innovation Act of 1980, as amended, 15 U.S.C. 3710a.The Baldrige Awards
Program was created under public law 100-107 The Malcolm Baldrige National Quality Improvement Act of 1987. 5 U.S.C. App.Inspector General Act of 1978, § 2; 5 U.S.C. App.-Reorganization Plan of 1970, § 2; 13 U.S.C. § 2; 13 U.S.C. § 131; 15 U.S.C. § 272; 15
U.S.C. § 1151; 15 U.S.C. § 1501; 15 U.S.C. § 1512; 15 U.S.C. § 1516; 15 U.S.C. § 3704b; 16 U.S.C. § 1431; 35 U.S.C.§ 2; 42 U.S.C. §
3121 et seq.; 47 U.S.C. § 902; 50 U.S.C. App. § 2401 et seq.; E.O. 11625; 77 FR 49699 (Aug. 16, 1012).
Purpose: The National Institute of Standards and Technology (NIST) oversees the Baldrige Performance Excellence Program (BPEP)
which is the nation' s only Presidential award for performance excellence and offers a wide array of award-winning products and services,
including the world-renowned Baldrige Excellence Framework. The function/purpose of the information collections is to support the
needs and activities of the internal and external customers in support of this mission.
Routine Uses: NIST will use this information to conduct necessary government business for the processing and the support needs of the
BPEP. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 522a) to be shared among NIST staff
for work-related purposes. Disclosure of this information is also subject to all the published routine uses as identified in the Privacy Act
System of Records Notices: COMMERCE/ DEPT- 18: Employee Personnel Files Not Covered by Notices of Other Agencies;
COMMERCE/DEPT-23: Information Collected in Connection with Department of Commerce Activities, Events, and Programs
Disclosure: Furnishing this information is voluntary, however, this information is required to obtain authorization to gain access to and
participate in the specified BPEP activity. The failure to provide accurate information may delay or prevent you from participating in the
activity. Submitting voluntary information constitutes your consent to the use of the information for the stated purpose.

OMB Clearance #0693-0006
Expiration Date: 06/30/2019
Page A-1 of 2

2019 Award Application Form
Malcolm Baldrige National Quality Award

1. Your Organization

4. Alternate Official Contact Point

Official name

☐ Mr. ☐ Mrs.

Mailing
address

Name
Telephone
Fax
Email

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

☐ Nonprofit
b. Criteria used (Check one.)
☐ Business/Nonprofit
☐ Education
☐ Health Care

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.
☐ Ms. ☐ Dr.

Name
Title
☐ Same as above

Overnight
mailing
address

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

Fax
Email

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

Mailing
address

(office and cell,
if possible)

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

Ethics Statement and Signature of
Highest-Ranking Official

3. Official Contact Point

Telephone

Release Statement

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/baldrigeaward/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.

☐ Health care

☐ Mrs.

5. Release and Ethics Statements

•
•
•

☐ Education

☐ Mr.

☐ Ms. ☐ Dr.

☐ Mr.

☐ Mrs.

Date
☐ Ms.

☐ Dr.

Printed name
Job title
Applicant name
Mailing address

☐ Same as above

Telephone
Email
Award package must be postmarked by April 23, 2019

OMB Clearance #0693-0006
Expiration Date: 06/30/2019
Page A-2 of 2

2019 Award Application Form
Malcolm Baldrige National Quality Award

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 (enclosed)
☐ Money order (enclosed)
Make payable to the Malcolm Baldrige National Quality Award.
☐ ACH payment

☐ Wire transfer

Checking XXXXXX

Before sending an ACH payment or wire transfer, notify the American Society for Quality (ASQ; [414] 765-7205, 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) 765-7205.
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 are unable to respond to any item, call (877) 237-9064, option 3,
before submitting your award application package.

2019 Award Application Form Checklist

OMB Control No. 0693-0006
Expiration Date: 06/30/2019

Malcolm Baldrige National Quality Award

1. Award Application Package
☐ I have included 30 individually bound paper copies of my organization’s application and 1 CD containing the

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 30 paper copies of the application each contain (and the CD version contains) the following sections, as well as
the labeled tabs or divider pages indicated in Application Content and Format webpage and Details document:
☐ blank front cover
☐ title page
☐ Table of Contents
☐ page A-1 of the 2019 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
☐ 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.
6. Submission
☐ I am submitting the award application package no later than April 23, 2019 (on paper and CD).
☐ 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) 765-7205

Award package must be postmarked by April 23, 2019