Authorization form

 

SEPA

Continuous authorization

Collector:

Stichting Gillissenvaarders, Oostertuinen 77 – 1944 SC – Beverwijk.  Nederland

Feature Authorization   NL48ZZZ631408370000 (Incassant-ID)

Reason for payment: annual contribution to foundation activities

 

By signing this fully completed form you give permission to the Gillissenvaarders Foundation,

  • send once-a-year ongoing collection instructions to your bank to debit an amount from your account and
  • to your bank to debit an annual amount from your account in accordance with the instruction of the Gillissenvaarders

 

If you do not agree with the debit you can have it reversed.

Please contact your bank for this within 8 weeks. Ask your bank for the conditions.

Name                                             

Address                                                                              City

Postal Code

Country

IBAN, your bankaccount nr:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bankidentificatie*

Place and date                                                         Signature

 

*Not required with Dutch IBAN

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