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 la Psicología 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