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The Copper Black International Award
for Creative Achievement
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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