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Registration Form

ACTIVE MEMBER REGISTRATION

DuPont/INVISTA Pensioners Association-Canada

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

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

Please Print


  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.

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Posted on Monday, 12 October 2020
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