Annual fee: 12.00$ for pensioners
6.00$ for the spouse or surviving spouse
Last Name: ______________________ First Name: ________________Date of birth: ___________(YY)____________(MM)_________(DD)
Employee Number: __________________Tel: (____)_______________
Address: __________________________________________________
City: _____________________________ Postal Code: _____________
Signature: __________________________ Date: _____________
E-mail address: _______________________________
Application or renewal for spouse:Last Name: ______________________ First Name:_________________
Date of birth: ___________(YY)____________(MM)_________(DD)
I wish to pay my Membership as follows:
Pensioner: (__) Enclosed is my cheque for 12.00$
Spouse or
Surviving spouse: (__) Enclosed is my cheque for 6.00$Make cheque payable to:VIA Rail Canada Pensioners' Association - Québec
Send your cheque and application form to:
Donald Bechamp, Treasurer
VIA Rail Canada Pensioners' Association - Québec
219 boul J. C. Michaud
St. Basile le Grand, QC
J3N 1E4
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