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Request for
Centenarian Recognition
Individuals who have reached the amazing age of 100 years are eligible to
receive recognition for that achievement.
The following information should be completed and submitted to:
The Division
for Aging Services
3416 Goni
Rd., #132
Carson City,
NV 89706
1. Name of the individual to receive the award:
___________________________________
2. Birth date of the centenarian:
______________________________________________
3. Current address of the centenarian:
_________________________________________
_______________________________________________________________________
_______________________________________________________________________
4. Any personal information that you would like shared (e.g. marital status,
number of children, life accomplishments, etc.).
____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
5. If you would like the recognition to be shared publicly (e.g. media
coverage), please attach a release of information that is signed by the
centenarian or his/her representative.
