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RETIREE REGISTRATION
Emp. No.:
Surname :   Firstname : Middlename :

I, , a Retiree of Chevron Corporation, having read all membership obligations and bye-laws hereby apply for membership of the Delta Area Chevron Employees Multi-Purpose Cooperative Society(DACEMPCS). I have paid the sum of to the DACEMPCS Accounts as the entrance fees and obtained a receipt numbered and dated .

CAI: Initials:
Retirement Date:
Format: MM/DD/YYYY 		Nationality:
Job Position : Employee Type ID :
Department : Employee Type Name :
Location : Unit Name :
Payroll Location : Section Name :
Phone Contact : Email Contact :
Next-Of-Kin : Savings Contribution Amt: