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:
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Bankidentificatie*
Place and date Signature
*Not required with Dutch IBAN