Dipac

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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

Renewal Registrations should only include your name and any changes in other information   since last registration.

Please Print

Name:…………………………………………………..

Address:………………………………………………..

City:…………………………..Province………………

Postal Code:……………………

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

e-mail:…………………………………….

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

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

Survivorship

At retirement, did you elect to leave a Joint & Survivor pension payable to your spouse upon your death?  Forms would have been signed…. (1) which specified the pension to be paid, or…(2) a waiver if none was the case. To facilitate continuing contact by DIPAC, if a pension was to be paid, please provide us with:

Name of Spouse: _______________________

The annual membership fee for 2011 is $10; Lifetime membership fee is $150.

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.

16 April 2011

 
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