LUF On line authorisation

On line authorisation

The undersigned hereby athorises the Foundation Leiden University Fund until further notice to deduct € 5 annually from his/her account.

Surname and Christian names:
M/F:	Male Female
Date of birth:
Address:
Post code:
Town / City:
Email:
Student number:
Bank/Giro account:

A sum of € 5 per year as contribution for student membership of the Leiden University Fund.

I would like to donate my € 5 to:
MANDELA STUDIE FONDS
MY OWN STUDY ASSOCIATION, namely

The authorisation is valid until further notice. To cancel, please contact the Leiden University Fund. If the payer is not in agreement of the debit, he or she can apply to the Postbank within 30 calendar days to request a reversal of this payment. Credits will be to bank account 45.17.133.703 in the name of ‘het Leids Universiteits Fonds, Rapenburg 61 te Leiden’ in the month of receipt and subsequently each year in March.

I agree.

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