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Direct debit form

Direct debit form

Bank: Agency:
Address: Town and post code:
Dear Sir/Madam,

I request that you make the necessary arrangements so that from the date ___/___/20__ , payments for the subscription to Psicodoc, from the Colegio Oficial de Psicólogos de Madrid, are deducted from my account __________________________________.

________________, __________ de 20__

(Signature of the account holder)

Colegio Oficial de Psicólogos de Madrid. Psicodoc.

Cuesta de San Vicente N 4, 6ª pl. 28008 Madrid | Tel: 34-91 541 99 99 | Fax: 34-91 559 03 03

E-mail psicodoc@cop.es