Fast Forward Intent-to-Apply Form
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4. HIGHEST RESPONSIBLE OFFICIAL
1. APPLICANT ORGANIZATION Applicant Organization Official Name Other or Previous Applicant Organization Name Applicant Organization Headquarters Street Address City County ZIP Code
6. APPLICANT DESCRIPTION Attach the following items to this page. Refer to instructions on the back of this form and each form referenced below. Form A -Business Factors Form B - Site Listing (if more than one site in Wisconsin) Form C - Subunit Designation (if a unit, department, division or like organization of a parent organization) Organizational Chart(s)
2. SIZE OF ORGANIZATION
2. SIZE OF ORGANIZATION Total number of sites in Wisconsin
3. ORGANIZATION TYPE
7. ASSURANCES AND AUTHORIZATION
7. ASSURANCES AND AUTHORIZATION Total FTEs in Wisconsin On Citizenship: We certify that our organization is a good community citizen, and that there are no current allegations, investigations, or violations of laws/regulations related to civil rights, health, safety, finances, tax status, environment, labor relations or similar issues that could be embarrassing to the Wisconsin Center for Performance Excellence (WCPE) or Wisconsin Forward Award. We agree to disclose any such issues to WCPE, and we understand that we may be asked to re-validate this certification before award levels are assigned. On Forward Award Application and Applicant Responsibility: We understand this Intent-to-Apply form and subsequent Fast Forward application to WFA will be reviewed by members of the WFA Board of Examiners. We further understand that all reviewers are required to follow the Forward Award Code of Ethics and Standards of Conduct to ensure confidentiality and avoid possible conflict of interest.
3. ORGANIZATION TYPE Manufacturing Health Care Government Service Education Other (Specify) NAICS Code (3 or 4 digits from pages 3 and 4 of this booklet): Check here if your organization is a Friend of Forward.
4. HIGHEST RESPONSIBLE OFFICIAL
4. HIGHEST RANKING RESPONSIBLE OFFICIAL Name of Organization’s Highest Responsible Official (WI) Title Street Address
______________________________________________________ Authorized Signature – Highest Responsible Official Name (please type or print)
City Telephone Number Email address
County Fax Number
ZIP Code Title FOR OFFICIAL USE ONLY
This confirms that the applicant organization on this Intent-to-Apply Form is eligible to apply for the 2010 Wisconsin Fast Forward.
5. OFFICIAL ORGANIZATIONAL CONTACT
Name of Official Contact Title Street Address City Telephone Number Email address County Fax Number ZIP Code
WFA, Inc. Authorized Signature
Confirmation Number: _______________________________
Intent-to-Apply Mailing Checklist: The intent-to-apply packet must include the original plus one copy of the following materials along with the $250 processing fee: Cover letter Intent-to-Apply form Organizational chart(s) Form A (Business Factors) Form B (Site listing, if applicable) Form C (Subunit designation, if applicable)
Instructions for Completing the Fast Forward Intent-to-Apply Form
Applicant Organization: Provide the official name,
business address, and all other information requested for the organization applying for the Wisconsin Forward Award.
Organizational Chart: Include as a separate
attachment a line and box organizational chart or charts for your organization. If your organization is a subunit of a larger organization, also attach a line and box organizational chart showing your organization’s relationship to the highest management level of the parent organization, including intervening levels. (See Form C for more details.) 7.
Size of Organization: Give the number of sites and the
number of full-time equivalent employees of the applicant organization as of the date you submit the form. This refers to sites and employees within Wisconsin. A site is considered a single site if the organization has offices or other works areas located near each other and if the organization considers them one location for business and personnel purposes.
Assurances and Authorization: The
signature of your organization’s highest responsible official in Wisconsin or designee is required. This indicates that your organization is a good citizen and will comply with the terms and conditions associated with being a Fast Forward participant and recipient.
Organization Type: Check the type of organization as
applicable, the appropriate NAICS Code for your organization from pages 3 and 4, and whether your organization is a Friend of Forward.
Highest Responsible Official: Provide the name and all
contact information requested for the highest responsible official of the applicant organization (Owner, Chair of the Board, President, CEO, Plant Manager, etc.). This is the person in Wisconsin with authority to commit your organization to the requirements of the Fast Forward process.
Mailing Checklist: The preparer of the Intent-toApply packet should review this checklist to ensure that all required items are included in the mailing package. Form B and/or Form C may not be applicable to your organization and therefore not included. A cover letter on organizational letterhead should accompany the Intent-toApply Packet.
Official Organizational Contact: Provide the name
and all other information requested for the applicant organization official who will serve as the primary contact throughout the evaluation process. Please designate a person who is knowledgeable about your organization and your application who will be able to provide additional information, answer inquiries if necessary.
Intent-to-Apply materials must be received no later than 30 days before the submission of your Fast Forward application and no earlier than six weeks before application. A non-refundable $250.00 fee is required. Please make check payable to Wisconsin Forward Award, Inc. or call us at (608) 663-5300 to arrange MasterCard, Visa, or Discover payment. Mail the Intent-to-Apply Packet and your check (if applicable) to: Wisconsin Forward Award, Inc. 2909 Landmark Place, Suite 110 Madison, WI 53713
Intent-to-Apply Supplementary Forms: All applicants
must complete and include Form A: Business Factors as a separate attachment. If you indicated in Section 2 that you have more than one site in Wisconsin, complete and attach Form B: Site Listings. If your organization is a subunit under a parent organization, complete and attach Form C: Subunit Designation. See the individual supplementary forms for more detailed information.
NAICS Three and Four Digit Codes
NAICS Code 11 111 112 113 114 115 21 211 212 213 22 221 23 236 237 238 31-33 311 312 313 314 315 316 321 322 323 324 325 326 327 331 332 333 334 335 336 337 339 42 423 424 425 2002 NAICS Title Agriculture, Forestry, Fishing and Hunting Crop Production Animal Production Forestry and Logging Fishing, Hunting and Trapping Support Activities for Agriculture and Forestry Mining Oil and Gas Extraction Mining (except Oil and Gas) Support Activities for Mining Utilities Utilities Construction Construction of Buildings Heavy and Civil Engineering Construction Specialty Trade Contractors Manufacturing Food Manufacturing Beverage and Tobacco Product Manufacturing Textile Mills Textile Product Mills Apparel Manufacturing Leather and Allied Product Manufacturing Wood Product Manufacturing Paper Manufacturing Printing and Related Support Activities Petroleum and Coal Products Manufacturing Chemical Manufacturing Plastics and Rubber Products Manufacturing Nonmetallic Mineral Product Manufacturing Primary Metal Manufacturing Fabricated Metal Product Manufacturing Machinery Manufacturing Computer and Electronic Product Manufacturing Electrical Equipment, Appliance, and Component Manufacturing Transportation Equipment Manufacturing Furniture and Related Product Manufacturing Miscellaneous Manufacturing Wholesale Trade Merchant Wholesalers, Durable Goods Merchant Wholesalers, Nondurable Goods Wholesale Electronic Markets and Agents and Brokers NAICS Code 44-45 441 442 443 444 445 446 447 448 451 452 453 454 48-49 481 482 483 484 485 486 487 488 491 492 493 51 511 512 515 516 517 518 519 52 521 522 523 524 525 53 531 532 2002 NAICS Title Retail Trade Motor Vehicle and Parts Dealers Furniture and Home Furnishings Stores Electronics and Appliance Stores Building Material and Garden Equipment and Supplies Dealers Food and Beverage Stores Health and Personal Care Stores Gasoline Stations Clothing and Clothing Accessories Stores Sporting Goods, Hobby, Book, and Music Stores General Merchandise Stores Miscellaneous Store Retailers Nonstore Retailers Transportation and Warehousing Air Transportation Rail Transportation Water Transportation Truck Transportation Transit and Ground Passenger Transportation Pipeline Transportation Scenic and Sightseeing Transportation Support Activities for Transportation Postal Service Couriers and Messengers Warehousing and Storage Information Publishing Industries (except Internet) Motion Picture and Sound Recording Industries Broadcasting (except Internet) Internet Publishing and Broadcasting Telecommunications Internet Service Providers, Web Search Portals, and Data Processing Services Other Information Services Finance and Insurance Monetary Authorities - Central Bank Credit Intermediation and Related Activities Securities, Commodity Contracts, and Other Financial Investments and Related Activities Insurance Carriers and Related Activities Funds, Trusts, and Other Financial Vehicles Real Estate and Rental and Leasing Real Estate Rental and Leasing Services
NAICS Code 54 541 55 551 56 561 562 61 611
2002 NAICS Title Professional, Scientific, and Technical Services Professional, Scientific, and Technical Services Management of Companies and Enterprises Management of Companies and Enterprises Administrative and Support and Waste Management and Remediation Services Administrative and Support Services Waste Management and Remediation Services
NAICS Code 72 721 722 81 811 812 813 814 92 921 922 923 924 925 926 927 928
2002 NAICS Title Accommodation and Food Services Accommodation Food Services and Drinking Places Other Services (except Public Administration) Repair and Maintenance Personal and Laundry Services Religious, Grantmaking, Civic, Professional, and Similar Organizations Private Households Public Administration Executive, Legislative, and Other General Government Support Justice, Public Order, and Safety Activities Administration of Human Resource Programs Administration of Environmental Quality Programs Administration of Housing Programs, Urban Planning, and Community Development Administration of Economic Programs Space Research and Technology National Security and International Affairs
Educational Services 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
Health Care and Social Assistance 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 71 711 712 713 Arts, Entertainment, and Recreation Performing Arts, Spectator Sports, and Related Industries Museums, Historical Sites, and Similar Institutions Amusement, Gambling, and Recreation Industries
Intent-to-Apply Form A: Business Factors
This information is used by WFA to screen and assign Examiner teams to avoid conflict of interest in application reviews.
A. Business/Organization Description
Provide a brief description of the nature of your business or organization (products, services, programs or technologies). You must conclude with a list of key competitors or indicate if no direct competitors exist.
B. Markets & Customers
Provide a brief description of the nature of major markets (local, regional, national, international). You must conclude with a list of key customers.
C. Suppliers, Dealers & Distributors
Provide a brief description of the importance of suppliers, dealers, distributors and franchises or partners. You must conclude with a list of key suppliers/partners and the type of product or service provided.
A. BUSINESS/ORGANIZATION DESCRIPTION
B. MARKETS AND CUSTOMERS
C. SUPPLIERS, DEALERS AND DISTRIBUTORS
Intent-to-Apply Form B: Site Listing and Description
A. Address of Site
Provide the complete street address and city of each site operating in Wisconsin, in addition to the Wisconsin headquarters identified on the Intent-to-Apply Form. (Only Wisconsin sites will be included in site visits.)
B. Relative Size
Provide the percentage of your organization’s employees at each site as of the date you submit this form. Provide the percentage of the total Wisconsin operating budget at each site.
C. Description of Services, Products, Programs, and/or Deliverables
Describe the key types of services, products, programs and/or other deliverables that are the output of the site. It may be necessary to state the relationship between the output of the site and your organization’s overall services, products, programs, and/or other deliverables. It is not necessary to list every service, product, program, and/or other deliverable.
A. ADDRESS OF SITE
B. RELATIVE SIZE
No. of Total Employees, Faculty or Staff % of Total Operating Budget
C. DESCRIPTION OF SERVICES
Services, Products, Program and/or Other Deliverables
Intent-to-Apply Form C: Subunit Designation
Complete only if the applicant organization is a unit or division of a larger (or parent) company. A. Is the applicant____________________ a larger parent or system? (Check all that apply.) a subsidiary of a division of controlled by B. Parent Organization Name: Address Line 1: Address Line 2: Title: Highest Ranking Official Name: a unit of a like organization of administered by a school of owned by
Number of worldwide employees of the parent: C. Is the applicant the only subunit of the parent organization intending to apply? Yes No Do not know
D. Briefly describe the major functions provided to the applicant by the parent or by other subunits of the parent. Examples of such functions include but are not limited to strategic planning, business acquisition, research and development, data gathering and analysis, human resources, legal services, finance or accounting, sales/marketing, supply chain management, global expansion, information and knowledge management, education/training programs, information systems and technology services, curriculum and instruction, and academic program coordination/development.
E. Is the applicant self-sufficient enough to respond to all seven Baldrige Criteria Categories? Yes No
If no, briefly explain: F. Briefly describe the organization structure and relationship to the parent.
G. Was the applicant independent prior to being acquired, and does it continue to operate independently under its own identity? Yes No