PERFORMANCE EXCELLENCE NORTHWEST (PENW)
Formerly Washington State Quality Award (WSQA)
2016 INTENT TO APPLY/ELIGIBILITY DETERMINATION FORM
This form is valid for one year from the date signed.
To file an Intent to Apply or a Lite or Full Application for assessment with PENW, Applicant’s headquarters
must be located in the state of Washington, Oregon, Idaho, or Alaska. If Applicant is not filing in the region
where headquarters is located, contact PENW to discuss. If approved, provide a brief explanation of the
special circumstances for filing with PENW (o.k. to attach a separate page if necessary):
APPLICANT INFORMATION
Applicant Name (use name as you would like it to appear in potential award):
Prior Names (if applicable):
Other Names (if applicable):
Address:
Telephone Number(s):
Has Applicant filed a prior WSQA or PENW?
SECTOR:
Business/Not-for-Profit;
Yes;
Healthcare;
No; If yes, when (year):
Education
CRITERIA: The Baldridge Excellence Framework is available ($10 PDF/$25 booklet). Go to: http://
www.nist.gov/baldrige/publications/purchase_criteria.cfm. The 2015/16 Lite Criteria is also
available online or contact Denise Swafford; dswafford@roguecc.edu.
INTENT/APPLICATION AND ASSESSMENT FEES
1. INTENT FEE $200.00 (Applicable to all applicants (LITE or FULL); and, due with submission of this
Intent to Apply Form).
2. APPLICATION DEADLINES AND FEES
LITE (Filing Deadline (Choose One)):
Jan. 1;
Apr. 1;
Jul 1;
Oct. 1
LITE (Assessment) Application Fee (determined by organization’s size (below)):
No. of Employees
0-50
51-250
251-500
501+
Examination Application Fee
$885.00
$1,500.00
$2,200.00
$2,800.00
Site Visit Administrative Fee
N/A
N/A
N/A
N/A
FULL (Filing Deadline): All full Applications must be filed by Dec. 1 for Jan. 1 Assessment:
FULL (Examination) Application Fee (determined by organization’s size (below)):
No. of Employees
0-50
51-250
251-500
501+
Examination Application Fee
$1,500.00
$3,500.00
$5,000.00
$6,200.00
Dec. 1
Site Visit Administrative Fee
$500.00 + Actual Expenses
$500.00 + Actual Expenses
$500.00 + Actual Expenses
$500.00 + Actual Expenses
CONTACT INFORMATION (Highest Ranking/Chief Officer in Applicant’s Organization)
Name:
Title:
Address:
Telephone Number(s):
Email:
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Official Contact Person for Organization (PENW Application Process)
Name:
Title:
Address:
Telephone Number(s):
Email:
Highest Ranking Official in Applicant’s State (Washington, Oregon, Idaho or Alaska):
Name:
Title:
Address:
Telephone Number(s):
Email:
Address Feedback Report to:
Name:
Address:
Telephone Number(s):
Chief Officer;
Official Contact Person;
Title:
Other (specify):
Email:
APPLICANT’S COMMITMENT: The Applicant must commit to providing at least one (1)
individual from the organization for examiner training one year prior to the application file date or
within the year the application will be filed and no later than the year following the date the
application is filed.
TRAINED EXAMINER(S) OR EXAMINER(S) COMMITTED TO TRAINING: (PENW
will notify Applicant’s examiner(s) of specific future training dates/location)
Name:
Address:
Telephone Number(s):
Training Completion Date:
Title:
Name:
Address:
Telephone Number(s):
Training Completion Date:
Title:
Email:
Intended Training Date:
Email:
Intended Training Date:
This Year;
Next Year
This Year;
Next Year
If Applicant, has more than two trained examiners or intends to train more than two examiners,
provide contact information on a separate sheet of paper.
SIZE AND LOCATION(S) FOR ORGANIZATION
Number of Employees:
Total Number of Sites:
If more than one site, list a brief description and complete address for each site (attach additional
sheet of paper if necessary):
SUBSIDIARY INFORMATION: (For example, is Applicant a unit, division, or other
function/component of a larger parent organization?
Yes;
No
If no, skip to Disclosure and Release Statement. If yes, answer the following information:
Name of Parent Organization:
Name of Highest Ranking Official:
Title:
Address:
Telephone Number(s):
Email:
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Rev.: Jan. 14, 2016
Indicate if other units within the parent organization offer similar products or services:
Yes;
If yes, briefly describe major business support functions provided from parent organization to
Applicant (attach additional sheet of paper if necessary):
No
DISCLOSURE AND RELEASE STATEMENT: The signing official attests that the
information provided in this Intent to Apply form and the Lite or Full Application to be submitted on
behalf of the Applicant is accurate and true to the best of his/her knowledge. Full disclosure of any
circumstances that may negatively affect an Award has been made with submission of this Intent to
Apply/Determination of Eligibility form. The signing official understands the PENW program may
verify this information, and that untruthful or misleading information may result in forfeit of an
Award. Also, the signing official certifies that the Applicant filing this Intent to Apply is not engaged
in any activity (past or present) that could be deemed embarrassing to the state where Applicant’s
business is located (Washington, Oregon, Idaho, or Alaska), to the state governor or to PENW.
The official signing this form further understands that he/she must immediately notify PENW if the
organization’s status changes during the next twelve months. If changes do occur, the Applicant may
be asked to revalidate this disclosure at that time.
WAIVER OF RIGHT TO BRING SUIT: PENW utilizes a security-enhanced online software
program to improve the productivity of its examiners. This program is provided to PENW, a nonprofit organization for the regional quality award program in Washington, Oregon, Idaho, and
Alaska and has licensed its software from Rocky Mountain Performance Excellence (RMPEX). The
agreement between PENW and RMPEX requires that Applicant’s waive their right to bring suit
against PENW and RMEX, their licensees, agents or assigns and releases them, their licenses, agents
or assigns from any claims, action, or losses arising from the use of the software in conjunction with
evaluating the Lite or Full Application document submitted by the Applicant. By submitting this Intent
to Apply, the Applicant waives its right to bring suit as defined above.
Yes;
No
The signing official also understands that members of the PENW Board of Examiners will be using
authorized cell phones, cordless phones, email, personal computers, laptops, and the
aforementioned, Web-based software program to review and discuss the Applicant’s Lite or Full
Application among team members, mentors, and PENW authorized individuals.
POTENTIAL SITE VISIT/EVALUATION: Further evaluation by site visit may be determined
by the PENW Examination Team. Not all applicants will be recommended for a site visit. Lite
Applications will never be scheduled for site visits.
If selected for an on-site evaluation, an additional fee of $500, plus expenses for each team examiner
(up to seven (7) examiners) will be required). The signing official agrees to host the PENW
Examination Team, arrange for meeting space, and other logistics necessary for the visit. The
Application-Organization will also participate in an open and unbiased review of the organization.
Signature:
Printed Name:
Date:
Its:_____________________
Title
Send this completed form, with $200.00 fee for Intent to Apply to: Performance Excellence Northwest,
c/o Denise Swafford, PENW Liaison, Rogue Community College, Grants Pass, Oregon 97527
541-956-7087 or dswafford@roguecc.edu
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