Mensa Foundation


 

Copper Black Award for Creative Achievement
Nomination Form

If you would prefer to print and mail in the nomination form you can download it here.


Nominee Information (Mensa membership required)
*Mensa Membership ID:
*First Name:
*Last Name:
Address:
City:
State:
Postal Code:
*Email Address:
*Phone Number:
Nominated By: Self Other
 
 
Nominator Information (Mensa membership NOT required)
Mensa Membership ID:
*First Name:
*Last Name:
Address:
City:
State:
Postal Code:
*Email Address:
*Phone:
 
 
Accomplishment Information
Subject of the Accomplishment:
(In 300 words or less, describe the problem, difficulty, or other circumstances that is addressed by the creative achievement. Include how long the problem has persisted, if known.)
 
Description of the Accomplishment:
(Describe the achievement. Please do not exceed one page for this section. Clippings from periodicals, professional journal articles, or other documents that provide objective evidence of the problem, implementation, recognition, significance, etc., may be attached to support the nomination.)
 
 
File Attachments (allowed types include .pdf, .doc, .wpd, .rtf, .txt)
1.
2.
3.
4.
5.
 




  These pages and all content copyright ©2005 by American Mensa, Ltd. Mensa® and the Mensa logo are registered in the U.S. Patent and Trademark Office by American Mensa, Ltd., and are the registered marks of Mensa International, Ltd. in other countries.