Ubercart

Sketch of checkout pane of "Direct Debit Module"

_[V]__ *Direct Debit* ____________________________________________________________________

Debit authorization with right of objection

--CREDITOR--
[Shop-Owner], [Shop-Adress]

--ACOUNT TO CHARGE--
Account holder: _ _ _ _ _ _ _
Name of bank: _ _ _ _ _ _ _ _
Branch office: _ _ _ _ _ _ _ _
Bank clearing no. (if known): _ _ _ _ _ _ _
Postal code and City: _ _ _ _ _ _ _
IBAN or: _ _ _ _ _ _ _ _ _ _ _ _ _
Account no.: _ _ _ _ _ _

--ADRESS OF ACOUNT HOLDER--
[ ] Account information is the same as the delivery information. (closes
Name: _ _ _ _ _ _
Surname:_ _ _ _ _ _
Street:_ _ _ _ _ _
City:_ _ _ _ _ _
PostalCode:_ _ _ _ _ _
Region:_ _ _ _ _ _
Country:_ _ _ _ _ _

[ ] (Checkbox) I hereby authorize my bank to deduct debits in [currency] from the above-listed creditor directly from my account until this authorization is revoked. My bank is not liable to charge my account if the amount is not covered. For each direct debit i receive a debit note from my bank. Any debit will be charged back if i send back a signed debit advice to my bank within 8 weeks.

[NEXT] (Ubercart Checkoutpane Next Button)
____________________________________________________________________________