Withdrawal Form

I/we (*) hereby revoke the contract concluded by me/us (*) for the purchase of the following goods (*)/the provision of the following service (*)

_______________________________________________________

_______________________________________________________

Ordered on (*) ____________ / received on (*) __________________

________________________________________________________
Name of consumer(s)

________________________________________________________
Address of consumer(s)

________________________________________________________
Signature of consumer(s) (only if submitted on paper)

_________________________
Date

(*) Delete where inapplicable