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.