Withdrawal of direct debit authorisation
The undersigned hereby withdraws the authorization granted to Stichting Leids Universiteits Fonds for the following reason
First name
*
Surname
*
Address
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Email
*
example@example.com
Phone number
-
IBAN
*
Date of birth
*
-
Dag
-
Maand
Jaar
Datum
*
I hereby declare that I have completed the form truthfully. (By completing and submitting this form your current direct debit authorisation will be ended.)
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