Application for Membership
asbl
SEPA Direct Debit Mandate
Mandate reference – to be completed by EPSU-CJ
By signing this mandate form, you authorise (a) EPSU-CJ to send instructions to your bank to debit your account and (b) your bank to debit your account in accordance with the instructions from EPSU-CJ.
As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited.
Please complete all the fields marked *.
Your name	*
Name of the debtor
Your address	*
Street name and number
*
Postal code	City	Country
Your account number	*
Account number - IBAN
*
SWIFT BIC
Creditor’s name	EUROPEAN PUBLIC SERVICE UNION ASBL
Creditor's identifier	LU41 ZZZ 0000 0000 0869 9001 012
Creditor's address	B.P. 71, L-2010 Luxembourg	Type of payment	Recurrent payment
Date of birth	*	Nationality
Day	Month	Year
In case you work part-time, please indicate percentage	%	Grade
Optional:	Private telephone number
(required if you are a pensioner)	Private e-mail address
Collection due on the	1st day of the month	15th day of the month
every month	every 3 months	every 6 months
I hereby authorise the European Public Service Union - Court of Justice (EPSU-CJ) to adapt the amount of my subscription (see overleaf) in accordance with its Constitution (Art. 12) and its General Meetings’ resolutions. I authorise the EPSU-CJ to record and process in its personal database my union membership.
By joining, I accept the trade union’s Constitution (see http://epsu-cj.lu/nos_statuts)
> SEPA Direct Debit Mandate
City or town in which you are signing	Date	*
Location	day / month / year
Signature
Please print this form and sign here	*
Note: Your rights regarding the above mandate are explained in a statement that you can obtain from your bank.
Please return to:	(by internal mail) EPSU-CJ, MO/06 0012, Cour de justice de l'UE
(through the Post Office) EPSU-CJ, B.P. 71, L-2010 Luxembourg