Banking authorisation form

Banking authorisation form 2017-08-23T14:05:15+00:00

Lastname

Initials

Frequency
OnceMonthlyQuarterlyAnnually

Donation amount (in euros)

Project to be supported

Your gift is intended for this project

Account number

In the name of

City

Any comments on donation

Hereby, I authorize the GlobalRize Netherlands Foundation to charge the above amount once / periodic. This amount is a donation to the foundation. There is a 30-day legal refusal period. With periodic authorizations, the amount will be charged on the first day of the month.

Your email address

Fill in if you want to receive a copy of the authorization by e-mail.