Volunteer Request Form

Georgia SHIP provides personalized counseling and assistance to people with Medicare and their families. As a Georgia SHIP volunteer, you can make a difference in the lives of seniors throughout Georgia. Medicare training and certification are provided. Licensed insurance agents are unable to volunteer with the program.

First Name (required)

Last Name (required)

Phone

Email (required)

Confirm email (required)

Address (required)

Address 2

City (required)

State

Zip Code (required)

County (required)

Do you have an active license to sell insurance of any kind? (required)

Comments

(Please Note: Do not include your Medicare, Social Security Number or Date of Birth)

Volunteer Request Form

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