Examiner Application

Application for: 2010 Kentucky Center for Performance Excellence Board of Examiners

Please complete all sections of the application and click submit Returning examiners from previous year only need to complete pages two and five. If your job situation has changed in the last year, please also complete page three. The application deadline is September 4, 2010.

Kentucky Center for Performance Excellence
Board of Examiners Selection
C/O Daniel Dufresne
827 Isaac Shelby Circle
Frankfort, KY 40601
TEL: 502-695-8973

Title First Name M.I. Last Name

Employer Title

Preferred Mailing Address

Street City State Zip

FedEx Delivery Address (no P.O. Box)

Primary Phone (Work) Secondary Phone (Home) Fax

Email Address

NAICS Code(s): (Click here for code list, select most relevant to expertise:

1 2 3 4

If you have been a KYCPE Examiner previously, list the year(s): Years

Are you an Examiner for any other type of award program?
Yes
No

If yes, Please specify which award(s):

Experience

For the positions you have held during your professional career, please provide the information requested. Describe your last three positions. List your most recent position first. Use additional pages if necessary.

Current Employer Number of Employees

Complete Address of Employer Dates of Service Status

Job Title Number of Employees Supervised

Supervisors Name Title NAICS Codes of Employer

Types of Products or Services Parent Company (if applicable)

Experience in quality associated with this job

Previous Employer Number of Employees

Complete Address of Employer Dates of Service Status

Job Title Number of Employees Supervised

Supervisors Name Title NAICS Codes of Employer

Types of Products or Services Parent Company (if applicable)

Experience in quality associated with this job

Previous Employer Number of Employees

Complete Address of Employer Dates of Service Status

Job Title Number of Employees Supervised

Supervisors Name Title NAICS Codes of Employer

Types of Products or Services Parent Company (if applicable)

Experience in quality associated with this job

Please indicate your level of ability to evaluate applications in the seven Categories of the Criteria for Performance Excellence.

Criteria for Performance Excellence

Leadership	None Very Little Proficient Expert
Strategic Planning	None Very Little Proficient Expert
Customer and Market Focus	None Very Little Proficient Expert
Measurement and Analysis	None Very Little Proficient Expert
Human Resource Focus	None Very Little Proficient Expert
Process Management	None Very Little Proficient Expert
Results	None Very Little Proficient Expert

Please Indicate your ability to evaluate applications in the following sections.

Manufacturing	None Very Little Proficient Expert
Service	None Very Little Proficient Expert
Small Business	None Very Little Proficient Expert
Health Care	None Very Little Proficient Expert
Education (P-12)	None Very Little Proficient Expert
Post-Secondary Education	None Very Little Proficient Expert
Public Sector	None Very Little Proficient Expert

Please Indicate your level of skills in the following areas.

Management	None Very Little Proficient Expert
Analysis of Results	None Very Little Proficient Expert
Written Communication	None Very Little Proficient Expert
Leadership	None Very Little Proficient Expert
Interpersonal Relations	None Very Little Proficient Expert
Training or Education	None Very Little Proficient Expert

Education and Training Background

Education and Background Please list the name and location of post-secondary institutions, majors, attending dates and degrees received. Include significant formal training in quality.

Publications/Major Reports/Major Speeches Relevant to Quality

Publications/Major Reports/Major Speeches List the title and citation of your most recent publications or reports first (limit five examples). List the file and audience of major speeches during the past two years.

Outreach Activities, Achievements, Recognition and/or Professional Affiliations Outreach Activities, Achievements, Recognition

Describe why you want to become a member of the KYCPE Board of Examiners

Examiners who have not ever attended Examiner Training in Kentucky, National, or any other state required to attend a one-day New Examiner Orientation. Please select a day.

Sept. 25 Midway College
Sept. 29 Midway College

All Board of Examiner members must participate in one two-day examiner preparation training course. Please indicate your choice below.

Oct. 21-22 Midway College
Dec. 9-10 Louisville TBD

Name for Examiner Training Badge

Name for Examiner Certificate

I attest to the accuracy of the information in this application. I have read the Examiner general information and requirements and understand the commitment I am making to the Kentucky Center for Performance Excellence. If I am chosen to be an Examiner, I will abide by the Code of Ethical Standards and the Terms and Conditions of Appointment.

Initials Required

There is no charge for the two day all examiner training sessions provided that individuals agree to serve as examiners for the current examination year and execute defined examiner responsibilities. Please see the KYCPE website for these responsibilities and the training fee for non participants.

Attendees who participate in the new examiner orientation only and who elect not to attend the all examiner two day sessions have no further obligation to KYCPE. There is no charge for this training. We hope that individuals will use the knowledge gained for the pursuit of performance excellence within their organizations and consider becoming full fledged examiners in the future.

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KYCPE is a non-profit 501(c)(3) organization.