Registration Form

ACTIVE MEMBER REGISTRATION

Print, complete this page and mail, with the appropriate Annual Dues, to;

Janice Daly, Treasurer, DIPAC
6424 Warbler Lane
Mississauga, ON L5N 6E2

□ New Registration Please complete all sections.	□ Renewal Registration Renewal Registrations should only include your name and any changes in other information since last registration.
Pensioner Information Name: ______________________________________________________________________________________
Address: ____________________________________________________________________________________
City: _________________________________________	Province: ______	Postal Code: _______ _______
Phone: ( __________ ) __________ - ______________	Fax: ( __________ ) __________ - ______________
e-mail: ______________________________________________________________________________________
Year of Retirement: __________________________
Location at Retirement: _________________________________________________________________________
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: ________________________________________________________________________________
Fees Annual Membership - □ 1yr/$20 \| □ 2yr/$40 \| □ 3yr/$60 \| □ 4yr/$80 \| □ 5yr/$100
Please make cheques payable to: DuPont/INVISTA Pensioners Association-Canada.