Centenarian Recognition Request Form

Please complete this form to request a certificate of recognition for a Georgian who will turn 100 or older. Submissions are due at least 45 days in advance of the honoree's birthday.

What is the phone number where the honoree or his/her caregiver can be reached?

Provide area code and phone number. Leave blank if the contact person resides with the honoree.

Contact Person

First Name (required)

Last Name (required)

What is the contact person's relationship to the honoree? (required)

Street Address (required)

Address Line 2

City (required)

State (required)

Zip Code (required)

Phone Number (required)

Email Address (required)

Will there be a birthday celebration?

Yes

Not sure

Is the honoree able to easily carry on a short conversation with others?

Yes

With assistance

Briefly tell us about the honoree's life and what makes him or her unique. (required)

Note: The Georgia Department of Human Services may ask the person being honored (or his/her legal representative) to sign a photo/video release agreement.

What is the name of the person to be honored? (required)

Print the name of the centenarian as it should appear on the certificate.

When was the honoree born? (required)

The Georgia Department of Human Services Division of Aging Services or your local Area Agency on Aging will request proof of age before issuing a recognition certificate.

What is the address of the honoree?

Street Address (required)

Address Line 2

City (required)

Zip Code (required)

Centenarian Recognition Request Form

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