2011 Intent to Apply/Eligibility Form



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2011 Intent to Apply/Eligibility Form



Intent to Apply/Eligibility Form (for Level 2, 3 & 4 applicants only)

Tennessee Center for Performance Excellence Award Program


  • Save this form to your computer, then complete.

  • So that we can determine your eligibility for a Level 2, 3 or 4 Award, please submit 15 copies of both this Intent to Apply/Eligibility form and your Organizational Profile (see pages 4-6 of the 2011 TNCPE Criteria for Performance Excellence) to the TNCPE office (address below).

  • Mail the $150 Intent fee with these documents to the TNCPE offices (address below).

  • Intent to Apply documents and fee must be postmarked by July 1, 2011.

  • Additional instructions can be found in Section II of this form.

  • Please note, this form is to be used by Level 2, 3 and 4 applicants only. Level 1 applicants need only fill out the Level 1 application form on page 81 of the 2011 TNCPE Criteria for Performance Excellence (also available online).

  • If you have any questions, please call us: (615) 889-8323 or (800) 453-6474.


TNCPE office address

Tennessee Center for Performance Excellence

2525 Perimeter Place Drive, Suite 122

Nashville, TN 37214-3773

Intent Form Section I: Applicant Information

Please type or print
1. Applicant

     ____________________________________________________________

Organization name as it will appear on award


     ____________________________________________________________

Address
     _________________________     _______________     __________

City County Zip
2. Size and Locations

Total # of employees (full-time equivalent)      __

Total # of sites      ____
3. Industry Sector

Please check the sector that best describes your organization

 Manufacturing  Education  Service

 Government  Health Care Nonprofit


4. Industrial Classification

List up to three NAICS codes that best describe your organization

(See page 7 of this form.)
     _________      ______________      ______________
5. Official Contact
     ____________________________________________________________

Name
     ____________________________________________________________

Title
     ____________________________________________________________

Mailing address


     ____________________________________________________________

Street address (no PO Box)


     ____________________     _________________     _____________

City County Zip




     _________________________     _____________________________

Telephone Fax


     ___________________________________________________________

E-mail
6. Alternate Official Contact


     ___________________________________________________________

Name
     _________________________     _____________________________

Telephone Fax
     ____________________________________________________________

E-mail
7. Return Applicant? Yes      __ No      __

Application year(s):
­­_________________________________________________________________
8. Highest Ranking Official
     ____________________________________________________________

Name
     ____________________________________________________________

Title
     ____________________________________________________________

Address
     ___________________     _________________________     ______

City County Zip
     ___________________     _____________________________________

Telephone Fax


     _____________________________________________________________

E-mail
9. Identify Application Level

(See award level descriptions on pages vii-viii of the 2011 TNCPE Criteria for Performance Excellence)
Check One:  2  3  4
10. One-Sentence Organization Description

Please provide a brief description of your organization to be used for publicity and recognition.


________________________________________________________________
________________________________________________________________
________________________________________________________________
11. Intent Fee and Mailing Address

Enclose $150 Intent Fee (non-refundable) made payable to TNCPE to cover initial processing and eligibility determination. With your Intent Fee, mail 15 copies of your Intent to Apply/Eligibility Form and Organizational Profile to:


Tennessee Center for Performance Excellence

2525 Perimeter Place Drive, Suite 122

Nashville, TN 37214-3773


Intent Form Section II: Instructions

Please type or print.
1. Applicant

Use these fields to provide the official name and address of your organization as it will appear on the award and publicity material.


2. Size and Locations

Provide the number of full-time equivalent employees (FTE) working at the organization. Indicate the number of sites to be included in the evaluation.


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.


3. Industry Sector

Please select the sector that best describes your organization.


4. Industrial Classification

Insert the North American Industry Classification System (NAICS) codes most relevant to your organization’s products and/or services (see page 7 of this form). If you wish to access the NAICS codes online, go to www.census.gov/naics.


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 authority to provide additional information and arrange a site visit. If the official or alternate contact changes during the course of the application process,

please inform TNCPE.
7. Return Applicant?

Indicate if the organization is a return applicant and the year(s) of application.


8. Highest Ranking Official

In these fields, provide information about the organization’s highest ranking official: owner, CEO, president, chairman of board, plant manager, etc.


9. Identify Application Level

Please choose the level of recognition for which your organization is applying.

Level 2 - Commitment Award

Level 3 - Achievement Award

Level 4 - Excellence Award
10. One-Sentence Organization Description

Provide a brief description of your organization. This description will be used in conjunction with the Excellence in Tennessee Awards Banquet and for publicity purposes.


11. 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 or credit

card. Submit your payment with this Intent Form.
Organizational Profile

Fifteen copies of your Organizational Profile must be submitted with this Intent Form. The Organizational Profile must be no longer than 5 pages and respond to the questions on pages 4-6 of the 2011 TNCPE Criteria for Performance Excellence. Inclusion of a glossary of terms and abbreviations, as well as an organizational chart, is strongly encouraged. The glossary and organizational chart do not count in the Organizational Profile’s 5-page limit.


Please note: The number of pages in the Organizational Profile does not count toward the organization’s Criteria response that will be submitted with the Application Form by August 1, 2011 for the 2011 award cycle.
Submitting your Intent to Apply/Eligibility Packet

Your Intent to Apply Packet should include:



  • 15 copies of the Intent to Apply/Eligibility Form

  • 15 copies of your Organizational Profile

  • $150 Intent Fee

Mail these items to the Tennessee Center for Performance Excellence postmarked by


July 1, 2011, for the 2011 award cycle.
Tennessee Center for Performance Excellence

2525 Perimeter Place Drive, Suite 122

Nashville, TN 37214-3773

(800) 453-6474



North American Industry Classification System (NAICS) Codes
Please insert NAICS codes most relevant to your organization’s products and/or services on the first page of the Intent to Apply/Eligibility Form or Application Form.


111 Crop Production

112 Animal Production

113 Forestry and Logging

114 Fishing, Hunting and Trapping

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

314 Textile Product 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

452 General Merchandise Stores

453 Miscellaneous Store Retailers

454 Nonstore Retailers

481 Air Transportation

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)

517 Telecommunications

519 Other Information Services

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

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, and 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

Tennessee Center for Performance Excellence
(800) 453-6474 • www.TNCPE.org page


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