Copper Black Award nomination

Nominee Information (Mensa membership required)

Mensa Membership ID:

First Name:

Last Name:

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City:

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Postal Code:

Email Address:

Phone Number:

Nominated By:

Self

Other

Nominator Information

Mensa Membership ID:
(Mensa membership not required)

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Last Name:

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City:

State:

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Phone:

Accomplishment Information

Subject of the Accomplishment

In 300 words or fewer, 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, including the estimated number of people impacted. Please limit your answer to 500 words or fewer.

File Attachments (PDF files only)

Please include 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.

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