Direct Debit Form SUEPO/VEOB The Hague

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 authorize:

(A) the "Vakbond van het Europees Octrooibureau (VEOB), afdeling Den Haag," with Creditor Identifier NL08ZZZ404113920000, to send instructions to your bank to debit your account for the annual payment of your SUEPO membership fee (recurrent), and

(B) your bank to debit your account in accordance with the instructions from SUEPO/VEOB The Hague.

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 56 calendar days 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 can be revoked by submitting a written notice to SUEPO The Hague through the contact form on our website.
Signature

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Date

MonthDayYear
Date
Should be Empty:

Direct Debit Form (SEPA)