Honoring Our Centenarians
A Century of Life. A Legacy Worth Celebrating. A special initiative by the City of Jacksonville Senior Services Division to recognize and honor residents who reach the incredible milestone of 100 years of age.
Name of nominee
*
First Name
Last Name
Address of nominee
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact number for nominee
*
Please enter a valid phone number.
Format: (000) 000-0000.
Nominee's date of birth
*
-
Month
-
Day
Year
Date
Your name
*
First Name
Last Name
Your email address
*
example@example.com
Your phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please upload a picture (not required)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature- I certify that the information provided is true and accurate to the best of my knowledge.
*
Continue
Continue
Should be Empty: