Mandate for recurrent collections on behalf of Friends of the MSS Research Foundation I am a friend of the MSS Research Foundation. I authorise the MSS Research Foundation to send recurrent collection instructions to my bank to debit my account and my bank to debit my account on a recurrent basis. The amount is:Euro Please fill in the amount in Euros This amount is: Yearly Every six months Quarterly MonthlyName Please fill in your name Street and number Please fill in your street and number Postal code Please fill in your postal code City Please fill in your city Email Please fill in your email address Bank account number Please fill in your Bank account number Yes, I would like to recieve the MSS newsletter (max. 3 times per year) You will receive a confirmation mail.As parts 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. Ask your bank for the conditions.Thank you for your support!MSS (Marshall-Smith Syndrome) Research Foundation | Oeverbiesstraat 20 | 2548 WP The Hague | The Netherlands | www.marshallsmith.org | info@marshallsmith.org | Registered KvK 27309021 | RABOBANK NL83 RABO 0140 3511 59 Enter verification code Powered by ChronoForms - ChronoEngine.com
