CANADA LIFE CANADIAN PENSION PLAN MEMBERS' RIGHTS GROUP

 APPLICATION FORM FOR VOTING MEMBERSHIP

Please Print

SURNAME __________________________________   FIRST NAME ___________________________

ADDRESS ___________________________________________________________________________

CITY _______________________________   PROV___________   POSTAL CODE ________________

TELEPHONE NO.     RES (            ) - _____________________  BUS (             ) -  __________________

EMAIL  ______________________________________________________________________________

MEMBERSHIP CATEGORY: (Circle the appropriate category)

EMPLOYEE       PENSIONER     DEFERRED PENSION    TERMINATED       BENEFICIARY

DATE OF COMMENCEMENT OF WORK AT CANADA LIFE (mm yyyy)  _________________________

IF NOT STILL EMPLOYED AT CANADA LIFE, DATE OF TERMINATION (mm yyyy) _______________

INITIATION FEE:                                   $100.00

ANNUAL MEMBERSHIP FEE:                    25.00

VOLUNTARY CONTRIBUTION:   $     (Optional, but appreciated, if any!)

TOTAL PAYMENT ENCLOSED:  $    _________

PAYMENT MODE (circle the appropriate mode) CASH               or         CHEQUE

**Cheques can be payable to "CLPENS GROUP"   or, if you wish, to the full name:

            CANADA LIFE CANADIAN PENSION PLAN MEMBERS' RIGHTS GROUP

** If you are sending payment by mail, please address to:

CLPENS GROUP

P.O. BOX 37036

6502 YONGE ST.

NORTH YORK, ONT.

M2M 4J8

IF YOU ARE WILLING TO HELP BY WORKING WITH THE GROUP, PLEASE DESCRIBE BELOW WHAT TYPE

OF ASSISTANCE YOU COULD OFFER.

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ANY OTHER COMMENTS   ________________________________________________________________

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