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.

Print the name of the centenarian as it should appear on the certificate.
When was the honoree born?
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?
This question is for testing whether you are a human visitor and to prevent automated spam submissions.