ENROLMENT FORM - SURVIVING SPOUSE

ENROLMENT FORM - SURVIVING SPOUSE
I, _______{name}________________hereby authorize the CBC Pensioners 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.
Please Print
Name
CBC ID (See Notification of deposit)
Address:

Street Address

Street Address Line 2

CityProvince

Postal Code
Telephone
Format: (000) 000-0000.
Date of Birth (dd/mm/yyyy)

DayMonthYear
Date
Gender (optional)
Preferred language

EnglishFrench
E-Mail:
example@example.com
Information on Deceased Pensioner
Name
CBC ID Number
Date of Death (dd/mm/yyyy)

DayMonthYear
Date
Signature
Date

DayMonthYear
Date
This form to be mailed to: CBC Pensioners Association P.O. Box 8570 Ottawa, ON K1G 3H9 or scan and email to: info@cbcpensioners.ca 1-877-361-9242
Should be Empty: