Direct Debit Form

Direct Debit Form (SEPA)

Direct Debit Mandate for Annual Membership Fee Payment
Personal Information
Name

First NameLast Name
Email (priv.)
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Details
Bank
IBAN
SWIFT-BIC
By signing this mandate form, you authorise (A) IGEPA, with Creditor Identifier
DE79IMU00001446175 to send instructions to your bank to debit your account for
payment of your SUEPO membership fee annually and (B) your bank to debit your
account in accordance with the instructions from IGEPA.

As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.

This mandate is revocable by sending a written notice to IGEPA.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Direct Debit Form (SEPA)