Model Withdrawal Form

(If you wish to cancel the contract, please fill out this form and send it back to us.)

I/we (*) hereby give notice that I/we (*) cancel my/our (*) contract for the purchase of the following goods (*) / for the provision of the following service (*):

_______________________________________________________

Ordered on (*): __________ / Received on (*): __________

Sender:

Name: _________________________________________________

Address: ______________________________________________

_________________________
Signature (only if notified on paper)

Date: __________

(*) Delete as appropriate.