MODEL WITHDRAWAL FORM

I/we (*) hereby give notice that I/we (*) withdraw from my/our (*) contract of sale of the following goods (*)/for the provision of the following service (*),

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Ordered on ___________________ (*)/received on _______________________(*)

Name of consumer(s) ______________________________________

Address of consumer(s)

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Date:________________

Signature of consumer(s):___________________________________________

 (only if this form is notified on paper)

(*) Delete as appropriate