SUPPORT PAY-IN-SLIP
ASSOCIATION FOR RESEARCH ON DIABETES & AUTO-IMMUNITY
-DEAR LAB-
Please fill in this slip and send it to: ASSOCIATION POUR LA RECHERCHE SUR LE DIABETE ET L’AUTO IMMUNITE -DEAR LAB, 8 Boulevard Jourdan, 75014 PARIS, France
Surname: __________________________ Name: _____________________
Address: _______________________________________________________
City: __________Area Code : ________________State :_______________Country:________
E-mail : _____________________
Phone: _______________________
I make a donation by check I make a donation by automatic bank withdrawal*
Of a total amount of: _________€ *(Please fill in the authorization below and attach your Bank Identification Form)
Date: ____/_____/_____ Signature: _________________________________________________________________________________
AUTHORIZATION OF AUTOMATIC WITHDRAWAL
FOR A LONGLASTING SUPPORT TO THE ASSOCIATION FOR THE RESEARCH OF DIABETES & AUTO-IMMUNITY -DEAR LAB
I choose to regularly help the Association DEAR LAB by making a monthly donation:
5 Euros 10 Euros 20 Euros ……… Euros
(Other amount)
I, myself, authorize the ASSOCIATION POUR LA RECHERCHE SUR LE DIABETE ET L’AUTO IMMUNITE -DEAR LAB to withdraw the above-mentioned amount and debit it to my bank account, till further notice. The first payment will take place at the signature of this form and the following each _____ of the month. I will be able to interrupt this agreement at any time.
BANK DETAILS
BANK NAME: ___________________ SWIFT CODE ____________________
IBAN n°____________________ _________
______________________________________
BANK ADDRESS: ___________________________________________________________________
CITY: _________AREA CODE: ______STATE:______________COUNTRY:__ ________________
ASSOCIATION FOR RESEARCH ON DIABETES & AUTO-IMMUNITY
-DEAR LAB-
Please fill in this slip and send it to: ASSOCIATION POUR LA RECHERCHE SUR LE DIABETE ET L’AUTO IMMUNITE -DEAR LAB, 8 Boulevard Jourdan, 75014 PARIS, France
Surname: __________________________ Name: _____________________
Address: _______________________________________________________
City: __________Area Code : ________________State :_______________Country:________
E-mail : _____________________
Phone: _______________________
I make a donation by check I make a donation by automatic bank withdrawal*
Of a total amount of: _________€ *(Please fill in the authorization below and attach your Bank Identification Form)
Date: ____/_____/_____ Signature: _________________________________________________________________________________
AUTHORIZATION OF AUTOMATIC WITHDRAWAL
FOR A LONGLASTING SUPPORT TO THE ASSOCIATION FOR THE RESEARCH OF DIABETES & AUTO-IMMUNITY -DEAR LAB
I choose to regularly help the Association DEAR LAB by making a monthly donation:
5 Euros 10 Euros 20 Euros ……… Euros
(Other amount)
I, myself, authorize the ASSOCIATION POUR LA RECHERCHE SUR LE DIABETE ET L’AUTO IMMUNITE -DEAR LAB to withdraw the above-mentioned amount and debit it to my bank account, till further notice. The first payment will take place at the signature of this form and the following each _____ of the month. I will be able to interrupt this agreement at any time.
BANK DETAILS
BANK NAME: ___________________ SWIFT CODE ____________________
IBAN n°____________________ _________
______________________________________
BANK ADDRESS: ___________________________________________________________________
CITY: _________AREA CODE: ______STATE:______________COUNTRY:__ ________________