2014 Applicant Intent to Apply/Eligibility Form
Keystone Alliance for Performance Excellence Intent to Apply
Application Level 1, 2, and 3
2014 Award Process
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This is a fill-in enabled form. It can be completed electronically.
This form is to be submitted by all Level 1, 2, and 3 Applicants.
Mail the completed Intent Form and the $150 Intent Fee to the KAPE Office; it must be
postmarked by January 6, 2014.
Additional instructions are provided in Section II of this form.
If you have any questions, please call us: 717-737-6470.
KAPE Mailing Address:
Keystone Alliance for Performance Excellence
Award Process
590 Centerville Road #260
Lancaster, PA 17601
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 1
Section I: Applicant Information
1. Applicant
Organization Name as it will appear on Award
Address
City
County
Zip
2. Size and Locations
Total number of employees (full-time equivalent) in the unit applying:
Number of those employees (full-time equivalent) in PA:
Percent of assets in PA:
Total number of sites in the unit applying:
3. Industry Sector
Please check the sector that best describes your organization:
Education
Government
Health Care
Manufacturing
Not for Profit
Service
4. Industrial Classification
List up to three of the most descriptive NAICS codes (see Section III of this form for a complete list of
codes):
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 2
5. Official Contact
Name
Title
Mailing Address
Street Address (no PO Box)
City
County
Telephone
Zip
Fax
E-mail
6. Alternate Official Contact
Name
Telephone
Fax
E-mail
7. Returning Applicant?
Yes
No
Application Year(s):
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 3
8. Highest Ranking Official
Name
Title
Address
City
County
Telephone
Zip
Fax
E-mail
9. Application Level
Check one:
Level 1
Level 2
Level 3
Description of Application
Organizational Profile and 15 page Category-Level Application
Organizational Profile and 50 page Item-Level Application
Organizational Profile, 50 page Item-Level Application, and Site Visit
Level 3 Site Visit Weeks
Level 3 applicants must 1st and 2nd choice for Site Visit Weeks
st
nd
Indicate 1 & 2 Choices:
June 9
June 16
June 23
Level 3 Education applicants should contact KAPE for a Site Visit Week that works within the school
calendar.
Please click on Application Info to go to the KAPE website for:
Fees associated with each Application level
The level of recognition available to Applicants at each Application Level
Organizations are judged within their respective sectors of Education, Government, Health Care,
Manufacturing, Not for Profit, and Service. Any number of organizations may receive Recognition or
Excellence Awards in each year.
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 4
10. Nomination of Examiners (required for all Applicants)
Application Level
Level 1
Level 2
Level 3
Examiner Requirement - Check one and enter the name(s)
1 Examiner Name:
1 Examiner
Name:
2 Examiners
Names:
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 5
11. One-Sentence Organization Description
Please provide a brief description of your organization to be used for publicity and recognition.
12. Applicant's Statement and Authorizing Signature
We certify that our organization meets the eligibility requirements of the Keystone Alliance for
Performance Excellence Award and the sector in which we intend to apply.
We understand that members of the Board of Examiners will review this application. We agree to
participate in the evaluation process, to facilitate an open and unbiased examination, and to reimburse
expenses incurred by the site visit team (Level 3 applicants only).
We understand KAPE's expectations of us as an Applicant to share our successful improvement
strategies and lessons from our performance excellence journey with other Pennsylvania organizations,
to participate in the annual KAPE Conference, and to use appropriate methods to communicate and
advertise recognition received through the KAPE Award Process.
Signature of Highest Ranking Official: _____________________________________________
Date: _____________________________________________
13. Intent Fee and Mailing Address
Enclose $150 Intent Fee (non-refundable) made payable to KAPE to cover initial processing and
eligibility determination.
Mailing Address:
Keystone Alliance for Performance Excellence
Award Process
590 Centerville Rd., # 260
Lancaster, PA 17601
Additional instructions for the Intent to Apply/Eligibility Form are provided in Section II of this form.
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 6
Section II: Instructions for Completing the Intent to Apply/Eligibility Form
Please type or print
1. Applicant
Use these fields to provide the official name of the organization as it will appear on the Award and on
publicity materials.
2. Size and Locations
Provide the number of full-time equivalent employees (FTE) working at the organization and the
number working in Pennsylvania.
Full-time equivalent employees are defined as those who regularly work 40 or more hours a week
and are entitled to benefits such as paid vacation, sick leave and insurance coverage. Each instance
of job sharing, where multiple individuals fulfill the responsibilities of a single position that requires
40 or more hours per week, is counted as a full-time equivalent employee.
KAPE defines small, medium, and large organizations as follows:
Small: Less than 100 total employees in the unit applying
Medium: 100 to 500 total employees in the unit applying
Large: More than 500 total employees in the unit applying
Indicate the percent of the organization's total assets located in Pennsylvania.
Indicate the number of sites to be included in the evaluation.
3. Industry Sector
Please select the sector that best describes your organization. This information will determine the
Criteria KAPE will use to evaluate your application.
4. Industrial Classification
Insert North American Industry Classification System (NAICS) codes most relevant to the
organization’s products and/or services (see Section III of this form for a complete list of codes).
5. Official Contact
In these fields, provide complete contact information (using a street address for courier deliveries) for
the person at the organization who can provide additional information and arrange a site visit.
6. Alternate Official Contact
In the event the official contact is not available, please provide contact information for an alternate
contact with the authority to provide additional information or arrange a site visit. If the official or
alternate contact changes during the course of the application process, please inform KAPE.
7. Return Applicant
Indicate if the organization is a return applicant and if so, year(s) of previous application(s).
8. Highest Ranking Official
In these fields, provide information about the organization’s highest-ranking official (e.g., owner, CEO,
president, chairperson, plant manager)
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 7
9. Identify Application Level
Please choose the level of recognition for which your organization is applying. See level descriptions on
the KAPE web site.
10. Examiner Requirement
All applicants are required to provide Examiners for the Award Process, both to enhance your
organization's understanding of the Baldrige Criteria, and to ensure adequate resources for Application
evaluation. Please review Examiner responsibilities at Examiner Info on the KAPE website to help you
to select the appropriate individual(s). List the name(s) of the individual(s) in this section and ask the
individual(s) to submit an Examiner Application, also available at Examiner Info.
Please note that if you do not provide the required number of Examiner nominees, or an Examiner
nominee does not complete Examiner Training, your organization’s Award Application will not be
accepted. If an Examiner nominee completes Examiner Training, but does not participate in the Award
Process as an Examiner, KAPE will assess your organization an additional $500 fee.
11. One-Sentence Description
Provide a brief description of your organization. This description will be used in conjunction with the
KAPE Awards Banquet and for publicity purposes.
12. Signature of Highest Ranking Official
This form should be signed by the Highest Ranking Official listed in Section 8.
13. Intent Fee and Mailing Address
A $150 non-refundable Intent Fee is required to cover the costs associated with the initial processing and
eligibility determination. The Intent Fee may be paid by check. Submit your payment with the Intent
Form.
Submitting your Intent to Apply/Eligibility Packet
Your Intent to Apply Packet should include:
 Two copies of the Intent to Apply/Eligibility Form
 $150 Intent Fee
Mail these items to the Keystone Alliance for Performance Excellence, postmarked by January 6, 2012:
Keystone Alliance for Performance Excellence
Award Process
590 Centerville Road #260
Lancaster, PA 17601
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 8
Section III: North American Industry Classification
System (NAICS) Codes
Please insert the NAICS codes most relevant to your organization’s products and/or services on Section
I of your Application form.
Code/Sector
111 Crop Production
112 Animal Production
113 Forestry and Logging
115 Support Activities for Agriculture and
Forestry
211 Oil and Gas Extraction
212 Mining (except Oil and Gas)
213 Support Activities for Mining
221 Utilities
236 Construction of Buildings
237 Heavy and Civil Engineering Construction
238 Specialty Trade Contractors
311 Food Manufacturing
312 Beverage and Tobacco Product
Manufacturing
313 Textile Mills
315 Apparel Manufacturing
316 Leather and Allied Product Manufacturing
321 Wood Product Manufacturing
322 Paper Manufacturing
323 Printing and Related Support Activities
324 Petroleum and Coal Products Manufacturing
325 Chemical Manufacturing
326 Plastics and Rubber Products Manufacturing
327 Nonmetallic Mineral Product Manufacturing
331 Primary Metal Manufacturing
332 Fabricated Metal Product Manufacturing
333 Machinery Manufacturing
334 Computer and Electronic Product
Manufacturing
335 Electrical Equipment, Appliance and
Component Manufacturing
336 Transportation Equipment Manufacturing
337 Furniture and Related Product
Manufacturing
339 Miscellaneous Manufacturing
423 Merchant Wholesalers, Durable Goods
424 Merchant Wholesalers, Nondurable Goods
425 Wholesale Electronic Markets and Agents
and Brokers
441 Motor Vehicle and Parts Dealers
442 Furniture and Home Furnishings Stores
443 Electronics and Appliance Stores
444 Building Material and Garden Equipment
and Supplies Dealers
445 Food and Beverage Stores
446 Health and Personal Care Stores
447 Gasoline Stations
448 Clothing and Clothing Accessories Stores
451 Sporting Goods, Hobby, Book and Music
Stores
Keystone Alliance for Performance Excellence
717-737-6470• KeystoneAlliance.com
452 General Merchandise Stores
453 Miscellaneous Store Retailers
454 Nonstore Retailers
481 Air Transportation
Code/Sector
482 Rail Transportation
483 Water Transportation
484 Truck Transportation
485 Transit and Ground Passenger
Transportation
486 Pipeline Transportation
487 Scenic and Sightseeing Transportation
488 Support Activities for Transportation
491 Postal Service
492 Couriers and Messengers
493 Warehousing and Storage
511 Publishing Industries (except Internet)
512 Motion Picture and Sound Recording
Industries
515 Broadcasting (except Internet)
516 Internet Publishing and Broadcasting
517 Telecommunications
521 Monetary Authorities — Central Bank
522 Credit Intermediation and Related Activities
523 Securities, Commodity Contracts and Other
Financial Investments and Related Activities
524 Insurance Carriers and Related Activities
525 Funds, Trusts and Other Financial Vehicles
531 Real Estate
532 Rental and Leasing Services
533 Lessors of Nonfinancial Intangible Assets
(except Copyrighted Works)
541 Professional, Scientific and Technical
Services
551 Management of Companies and Enterprises
561 Administrative and Support Services
562 Waste Management and Remediation
Services
611 Educational Services
6111 Elementary and Secondary
Schools
6112 Junior Colleges
6113 Colleges, Universities and
Professional Schools
6114 Business Schools and Computer
and Management Training
6115 Technical and Trade Schools
6116 Other Schools and Instruction
6117 Educational Support Services
Continued on next page>
2014 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
page 9
Code/Sector
621 Ambulatory Health Care Services
6211 Offices of Physicians
6212 Offices of Dentists
6213 Offices of Other Health
Practitioners
6214 Outpatient Care Centers
6215 Medical and Diagnostic
Laboratories
6216 Home Health Care Services
6219 Other Ambulatory Health Care
Services
622 Hospitals
623 Nursing and Residential Care Facilities
624 Social Assistance
711 Performing Arts, Spectator Sports, and
Related Industries
712 Museums, Historical Sites and Similar
Institutions
713 Amusement, Gambling and Recreation
Industries
721 Accommodation
722 Food Services and Drinking Places
811 Repair and Maintenance
812 Personal and Laundry Services
813 Religious, Grantmaking, Civic, Professional
and Similar Organizations
814 Private Households
921 Executive, Legislative and Other General
Government Support
922 Justice, Public Order, Safety Activities
923 Administration of Human Resource
Programs
924 Administration of Environmental Quality
Programs
925 Administration of Housing Programs, Urban
Planning and Community Development
926 Administration of Economic Programs
927 Space Research and Technology
928 National Security and International Affairs
999 Unclassified Establishments
Keystone Alliance for Performance Excellence
2013 Intent to Apply/Eligibility Form for Levels 1, 2, and 3
717-737-6470• KeystoneAlliance.com
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