(Fill in and send this form only if you wish to withdraw from the contract.)

I/We (*) hereby inform you that I/we (*) withdraw from our contract for the sale of the following goods / provision of the following service (*).

Why do you want to return the product?

Ordered on

Received on

Name(s) of consumer(s)

Order number

Address of consumer(s)

City

Country

IBAN account number

E-mail address (for confirmation) A confirmation of your withdrawal will be sent to this address.

Date

Additional information (optional)

I hereby revoke the agreement relating to the sale of the goods/services mentioned above.