Authorization Form for Donation

Name and surname

Address

ZIP code and address

Country

(Mobile) Phone number

E-mail

IBAN

Direct debit mandate ID A Seal: NL25ZZZ6019911640000.

Payment reference: this will be filled in by A Seal and will be provided to you.

I authorize the foundation A Seal Stellendam and Expo to pay:

MonthlyYearlyOne-off of an amount of

Euros from the account notified above.

Comments

When you press send, you mandate the direct debit as described above. Thank you very much for your contribution.