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Intellectual Benefits Award
Nomination Form

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)

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Intellectual Benefits Award Nomination Form

Intellectual Benefits Award
Nomination Form