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.

Provide area code and phone number. Leave blank if the contact person resides with the honoree.
Contact Person
Will there be a birthday celebration?
Is the honoree able to easily carry on a short conversation with others?
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.
Print the name of the centenarian as it should appear on the certificate.
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?