Dipac

ACTIVE MEMBER REGISTRATION

DuPont/INVISTA Pensioners Association-Canada

Complete this page and mail, with the appropriate Annual Dues, to

J.E.Hills, Treasurer, DIPAC
303-1903 Pilgrims Way
Oakville, ON     L6M 2X1

Please Print

Name: ......................................................................................................

Address: ...................................................................................................

City: ......................................................................... Province ..................

Postal Code: ...................................

Phone: (.......) ......................... Fax; (........) ............................

e-mail: ...........................................

If Survivorship Option was selected at Retirement, please indicate:

Name of Spouse: ..................

Year of Retirement:..............      Location at Retirement:.................................

New Registration.........                Renewal Registration........

The annual membership fee for 2010 is $10
Please forward your registration and dues at the earliest opportunity.

Please make cheques payable to: DuPont/INVISTA Pensioners Association-Canada. It continues to be ‘cost prohibitive' to provide for dues remittance via the Internet & our web site.      

Note: Renewal Registrations need only include your name and any changes in other information since last
registration. If you have Registered Online, you need only fill in your name