Online direct debit form

Please complete this form to authorize Portbase for monthly direct bank debits.

Complete the fields below

and authorise Portbase
Company name
Address
Address and number City Postal code Country
E-mailadress*
Chamber of Commerce number
VAT number
I want to add a financial contact
- Yes
- No
Name*
First name Last name
Telephone*
E-mailadress*
Use a different email address for the invoice
- Yes
- No
E-mailadress for invoice*
Name bank*
IBAN bank account*
BIC (Bank Identifier Code)*
Name of authorised representative*
Town/City*
By signing this form, you authorize Portbase to send ongoing direct debit orders to your bank to debit an amount from your account due to the purchase of one or more Portbase services. As well as continuously deducting an amount from your account in accordance with Portbase's order.
Signature of authorised representative listed on Chamber of Commerce registration*
Hold the cursor on the field shown above until your cursor changes into a pen. Now write your signature just as you would on a piece of paper. If you are not satisfied with your signature, you can try again by clicking on the icon in the lower right of the field. By signing this application, you are agreeing to the General Terms and Conditions of Portbase. These General Terms and Conditions have been deposited with the Rotterdam Chamber of Commerce on April 30, 2018.
Toestemming en akkoord*
- I give permission to Portbase to process my data
- I agree with the terms and conditions
Read our privacy statement.

Complete the fields below