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UTCPE Award Application Form

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					2012 Award Application Form                                                                     Page 1 of 3
University of Texas Center for Performance Excellence (UTCPE)

Submission Instructions
Complete this 3-page Award Application Form and deliver it to the UTCPE office.
        University of Texas Center at Austin Professional Development Center
        P.O. Box 7518
        Austin, TX 78713-7518

        Tel:     512-471-4633
        Fax:     512-232-6126
        Web:     www.utexas.edu/cee/cpe

The Award Application Submission Package should include:

Six hard copies and CD of Award Application Package:
  • Blank Cover Page
  • Title Page with Organization Name
  • Table of Contents
  • Organization Eligibility Form (copy)
  • Award Application Form (including Organization Chart)
  • Glossary of Terms and Abbreviations
  • Organizational Profile (4 pages maximum)
  • Responses to Categories 1–7 (according to Criteria Level)
Application Fee:
  • Business and Manufacturing
   $150 Application Fee
   Level One Fee - $1,595
   Level Two Fee - $1,895
   Level Three Fee- $4,250
  • Military and Not-for-Profit/Government Organizations
      $150 Application Fee
     Level One Fee - $1295
     Level Two Fee - $1,595
     Level Three Fee - $3,995
  • Education
      $150 Application Fee
     Level One Fee - $1295
     Level Two Fee - $1,595
     Level Three Fee - $3,500


Make check or money order payable to:
   University of Texas at Austin

You also pay by VISA, MasterCard or American Express by calling your credit card information to:
   Registrar, 512-471-4633




                    Contact the University of Texas Center for Performance Excellence (UTCPE) if you have any questions:
                                                  www.utexas.edu/cee/cpe * 512-232-9530
2012 Award Application Form                                                                          Page 2 of 3
University of Texas Center for Performance Excellence (UTCPE)


Provide all information requested.                                         5. Release and Ethics Statements

A copy of this 2012 Application Form must be included in each              a. Release Statement
of the 6 paper copies and CD of the application report.
                                                                           We understand that this application will be reviewed by
1. Applicant                                                               members of the Board of Examiners.
(Fields will expand as you type)
                                                                           Should our organization be selected for a site visit, we agree to
Applicant Name                                                             host the site visit and to facilitate an open and unbiased
Mailing Address                                                            examination.


                                                                           b. Ethics Statement and Signature of the Highest Ranking
                                                                           Official

                                                                           I state and attest that
2. Criteria being used (Check one.)
                                                                           (1) I have reviewed the information provided by my
    Business           Education          Health Care                          organization in this Application Package.

Level of application (Check one.)                                          (2) To the best of my knowledge

    I                      II             III                                            no untrue statement of a material fact is contained
                                                                                          in this Application Package, and
3. Official Contact Point
                                                                                         no omission of a material fact that I am legally
    Mr.    Mrs.            Ms.      Dr.                                                   permitted to disclose and that affects my
Name:                                                                                     organization’s ethical and legal practices has been
Title:                                                                                    made. This includes but is not limited to sanctions
Mailing Address:                                                                          and ethical breaches.

Overnight Mailing Address                                                  Date:
(Do not use P.O. Box number.)
                                                                           Signature

Telephone:
E-mail:                                                                        Mr.    Mrs.           Ms.     Dr.
                                                                           Printed Name:
                                                                           Title:
4. Alternate Official Contact Point                                        Applicant Name:
                                                                           Mailing Address:
    Mr.    Mrs.            Ms.      Dr.
Name:
Title:                                                                     Telephone:
Telephone:                                                                 Fax:
E-mail:




                        Contact the University of Texas Center for Performance Excellence (UTCPE) if you have any questions:
                                                      www.utexas.edu/cee/cpe * 512-232-9530
2012 Award Application Form                                                                                        Page 3 of 3
University of Texas Center for Performance Excellence (UTCPE)


3. Publicity Release
Please complete the following publicity release checklist to receive recognition and publicity:

1.      The Award Committee may wish to publicize specific Award events at any time during the Award process. Do we have your
permission to publicize your organization’s name?
   YES     NO
   YES, WITH THE FOLLOWING RESTRICTIONS:


2.        May we place a copy of your Application in the UTCPE Library Quality Resource Center?
     YES    NO
     YES, WITH THE FOLLOWING RESTRICTIONS:


3.        May we reproduce your Application for use by others?
     YES    NO
     YES, WITH THE FOLLOWING RESTRICTIONS:


4.        May we reproduce your Feedback Report for use by others?
     YES    NO
     YES, WITH THE FOLLOWING RESTRICTIONS:



5.      May we use your logo in publicizing your organization? If so, please attach a 2-inch “slick” of your logo or a color logo in an
EMS file on CD.
   YES     NO
   YES, WITH THE FOLLOWING RESTRICTIONS:



6.       May we use your photos/negatives in publicizing your organization? If so, please attach two photos/negatives or an electronic
photo file on CD.
   YES      NO
   YES, WITH THE FOLLOWING RESTRICTIONS:



7. SIGNATURE OF HIGHEST RANKING OFFICIAL

Name:

Title:

Signature:

Date:

Organization



                     Contact the University of Texas Center for Performance Excellence (UTCPE) if you have any questions:
                                                   www.utexas.edu/cee/cpe * 512-232-9530

				
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Description: University of Texas Center for Performance Excellence (UTCPE) 2012 Award Application Form