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STATEMENT REGARDING WITHDRAWAL FROM REMOTE AGREEMENT

I/We[*] hereby give notice that I/we[*] cancel my/our[*] contract of sale of the following goods[*]  /for the supply of the following service[*]:

____________________________________________________________________________

____________________________________________________________________________

ordered on[*]  _________________________ received on[*] _________________________

with order number[**] ________________________ ,

invoice/receipt number[**] ________________________ .

Name of consumer(s)       _________________________

Address of consumer(s)   _________________________

Signature of consumer(s)  _________________________

                                                 (only if this form is notified on paper)

Date _________________________

 

[*] Delete as appropriate.

[**] Providing these data is not necessary, but it will make the withdrawal process easier and faster. 

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