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Authorization
SEPA direct debit
Merchant name
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Merchant adress
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Merchant zip code / city
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Merchant country
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Merchant ID
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Authorization description
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By signing this mandate form, you authorise:
[naam_incassant] to send a collection instruction to your bank to debit your account
you authorise your bank to debit your account in accordance with the instructions from
[naam_incassant]
If you do not agree this collection. Please contact your bank in eight weeks after amortization. Ask your bank about the conditions.
Initials
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Name
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Adress
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Zipcode / city
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Country
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E-mail
*
IBAN (bank account)
*
*
=
Input is required