CBC PNA ENROLMENT FORM FOR RETIREE

ENROLMENT FORM – RETIREE
Name*
Street
City
Prov.
Postal Code
Telephone
Email
example@example.com
Association may contact me and, upon request, provide assistance with the enrolment process.

I wish to join now please fill in the remaining sections of this formI am uncertain about joining at this time. I understand that, with the information given above, a representative of the Association may contact me and, upon request, provide assistance with the enrolment process.
I,
, wish to join the CBC Pensioners National Association and

hereby authorize the CBC to deduct monthly membership dues from my pension cheque and remit them to the Association. I also authorize the CBC to provide the Association with such personal information relating to me as the Association may require to facilitate the administration of dues and other services related to the welfare of pensioners.

All personal information provided to the Association by you or by the CBC is held in strict confidence.

Membership dues are 0.32% of a member's gross pension payment. For every $1,000 of monthly pension, a member would contribute $3.20.
CBC ID (See Notification of deposit, above your name)
Date of birth

DayMonthYear
Date
Gender (optional)
Civil Status

SingleMarriedWidow/erDivorcedSeparatedCommon-Law
Preferred Language

EnglishFrench
Date of retirement

DayMonthYear
Date
Spousal Name
Date of birth

DayMonthYear
Date
Gender (optional)
CBC Employee

YesNo
CBC Retiree

YesNo
Please mail it to CBC Pensioners National Association P.O. Box 8570 Ottawa, ON K1G 3H9, or click 'Submit' below to send it via email.
Signature Required

Powered by Jotform SignClear
Date*

DayMonthYear
Date
Should be Empty:

ENROLMENT FORM – RETIREE