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Direct Debit Authorization Form

Please fill out this form so we can perform a one-off direct debit from your bank account.

Note: If you don't have all the account details available and are more comfortable with another payment method, please use the back button in your browser to go back and choose another payment option.

Date:

Bank Name:
Bank ABA Routing Number:
Bank Account Type:
Bank Account Number:
Name Account Holder:

Order Amount:
Order Email address:

I Authorize Kampshoff Consultance inc. to charge my bank with the order amount. This payment authorization is valid and to remain in effect for this single purchase unless I, notify Kampshoff Consultancy Inc. of its cancellation by sending written notice via email within 12 hours of approving this authorization.

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

July 2, 2018 5:13 pm CET

Direct Debit Authorization Form Uploaded by Wouter Kampshoff - admin@wakingherbs.com IP 83.247.45.164