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The Mensa Foundation
International Award for Benefit to Society
Nomination Form

Nominee Information (Mensa membership required)

*Country:

*Mensa Membership ID:

*First Name:

*Last Name:

Address:

City:

Postal Code:

*Email Address:

*Phone Number:

Nominated By:

Self Other

Nominator Information (Mensa membership NOT required)

*Country:

Mensa Membership ID:

*First Name:

*Last Name:

Address:

City:

Postal Code:

*Email Address:

*Phone:

Accomplishment Information

Subject of the Accomplishment:

Description of the Accomplishment: (please limit to 1000 words or less)

File Attachments (allowed types include .pdf, .doc, .wpd, .rtf, .txt)


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