Formulier 3A – ICCAP

First name

Preposition

Last Name*

E-mail address

Commitment Frequency

• One-off
• Monthly

Hoeveel wil je doneren?*

€ 

Hoeveel wil je doneren?*

• €5.00
• Other: €

Method of payment*

• Direct debit
• iDeal
• Bancontact
• Credit Card
• Paypal

Bank account number*

IBAN

BIC

I agree that AMBER Alert Europe periodically instructs my bank to debit the promised amount from my account. I also agree with the regulation of the European SEPA direct debit system*

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