Sample Withdrawal Form

(If you wish to withdraw from the contract, please complete this form and return it.)

To

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

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Ordered on (*)/ received on (*)

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Name of the consumer(s)

____________________________________

____________________________________

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Address of the consumer(s)

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Date, signature of the consumer(s) (only if notified on paper)

*) Delete as appropriate.