ENROLMENT FORM - SURVIVING SPOUSE

ENROLMENT FORM - SURVIVING SPOUSE
I,
, hereby authorize the CBC Pensioners National Association to have the
CBC deduct monthly membership dues from my pension cheque and remit them to the Association. I also authorize CBC to provide the Association with personal information relating to me that the Association may require in relation to the payment of dues and other purposes related to the welfare of pensioners.

I understand that the monthly membership dues might be modified from time to time by a resolution of the National Convention of the Association.

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.
Name
CBC ID (See Notification of deposit)
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Telephone
(dd/mm/yyyy) Date of Birth

DayMonthYear
Date
Email
example@example.com
Gender (optional)
Preferred language

EnglishFrench
Preferred method of communication

PostEmail
Information on Deceased Pensioner
Name
CBC ID Number
(dd/mm/yyyy) Date of Death

DayMonthYear
Date
Signature

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Date

DayMonthYear
Date
This form to be mailed to: The CBC Pensioners National Association P.O. Box 8570 Ottawa, ON K1G 3H9 or scan and email to: info@cbcpensioners.ca
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