ENROLMENT FORM – RETIREE

ENROLMENT FORM – RETIREE
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Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Telephone
Format: (000) 000-0000.
Email
example@example.com
I,__________{name}___________________________, wish to join the CBC Pensioners 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 faciliate 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 (dd/mm/yyyy)

DayMonthYear
Date
Gender (optional)
Civil Status

SingleMarriedWidow/erDivorcedSeparatedCommon-Law
Preferred language

EnglishFrench
Date of retirement (dd/mm/yyyy)

DayMonthYear
Date
Spousal information
Name

First NameLast Name
Date of birth (dd/mm/yyyy)

DayMonthYear
Date
Gender (optional)
CBC Employee

YesNo
CBC Retiree

YesNo
Signature Required
Date

DayMonthYear
Date
This form can be mailed to:
CBC Pensioners Association
P.O. Box 8570
Ottawa, ON K1G 3H9
or press the submit button to send via
email to info@cbcpensioners.ca
Tel: 1-877-361-9242
Should be Empty:

ENROLMENT FORM – RETIREE

Please print

Spousal information