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.
