Copper Black Award nomination

Nominee Information (Mensa membership required)

Mensa Membership ID:

First Name:

Last Name:

Address:

City:

State:

Postal Code:

Email Address:

Phone Number:

Nominator Information

Mensa Membership ID:
(Mensa membership not required)

First Name:

Last Name:

Address:

City:

State:

Postal Code:

Email Address:

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.

Choose first file

Choose second file

Choose third file

Choose fourth file

Choose fifth file

I certify that the accompanying submission is solely my own work, that I have read and understand the rules and conditions set above, and that I meet all of them. I agree to accept the judges' decisions as final. I understand that any award may be revoked, in the Mensa Foundation's sole discretion, for: failure to meet the rules and conditions; failure to embody the values, mission, and vision of the Mensa Foundation; committing acts that negatively affect the reputation and goodwill of the Mensa Foundation and/or American Mensa; acts of academic dishonesty or misappropriation; conviction of any felony or a crime involving moral turpitude; and/or falsifying information submitted with this application.