Sample Withdrawal / Termination statement
(fill in and return only in case of intention to withdraw / terminate the contract)
Recipient:
Tel:
E-mail:
I/We, the undersigned, declare that I/we exercise my/our right of withdrawal / termination in respect of the contract for the sale of the following product (s) or the agreement of the following service (please indicate the products):
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Date of conclusion of contract / date of receipt
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Consumer’s name:
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Consumer’s address:
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Signature of the consumer: (in case of paper declaration only):
_______________________
(signature)
Date: ……………………………………….........
