Donationform MMA

MACHTIGING SAFE-ROADS EUROAFRIQUE DEVELOPMENT
By signing this written and mutual agreement form, and as per terms written and agreed on the same, you authorize your bank to pay Stichting SAFE-ROADS EUROAFRIQUE DEVELOPMENT of:

Rekeningnummer: NL96 lNG 80531243818
Ten name van: M.E.M Quirijnen Balksterveste 6, 3432AB Nieuwegein The Netherlands
BSN: 114472269 Phonenumber:+37625274165 Email:4Quirie@gmail.com

Door ondertekening van dit schriftelijke en wederzijdse overeenkomstformulier en volgens de geschreven en overeengekomen voorwaarden, machtigt u uw bank om te betalen aan Stichting SAFE ROADS EURO AFRIQUE DEVELOPMENT:

Rekeningnummer: NL96 lNG 80531243818
Ten name van: M.E.M. Quirijnen Balksterveste 6, 3432A8 Nieuwegein Nederland
BSN:112M72269 Telefoonnr: 0625274165 Email:4Quirie@gmail.com

Van deze volmacht mag gebruik worden gemaakt in de volgende periode / This power of attorney may be used in the following period:-
The first day on which the power of attorney may be used / de eerste dag waarop de volmacht gebruikt mag worden is:
Date first day

MonthDayYear
The last day on which the power of attorney may be use/ de laatste dag waarop de volmacht gebruikt mag worden is:
date/datum:..{date8}
Date last day

MonthDayYear
AUTHORITY:
Hereby grant payment to:- refered to as 'sponsored party,' or 'beneficiary.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Name
Account ID No
IBAN No
BIC No
Reason for payment / Reden betaling
Personal details
Name

First NameLast Name
Date of birth / geboortedatum

MonthDayYear
Birthplace / geboorteplaatst
Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Passport / ID No.
Place of Issue / plaats van afgifte
Date of Issue / datum van afgifte

MonthDayYear
Date of Expiry / vervaldatum

MonthDayYear
Email
example@example.com
Phone Number / telefoonnummer

Area CodePhone Number
ACCEPTANCE:

SPONSORSH IP PAYMENT & COLLABORATION
- The Sponsor shall support the Organization by making sponsoring cost per student and trainer, administration, logistics, etc,
MONTHLY BASE
in Euro's
OR
- The Sponsor shall support the Organization by making sponsoring cost per student and trainer, administration, Iogistics
  etc.
YEARLY BASE
in Euro's
For the period of collaboration, the Sponsor may identify itself as a corporate sponsor. The sponsor may want included in any press releases or news letter statements regarding the Sponsor's being a corporate sponsor and in any information regarding the same.
Sponsorship Agreement:
Date

MonthDayYear
Expiring Date

MonthDayYear
Signature sponsor party, beneficiary:

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sponsor party, beneficiary
Should be Empty:

MACHTIGING SAFE-ROADS EUROAFRIQUE DEVELOPMENT