Specimen – Revocation Form

Model withdrawal form (If you want to cancel the contract, please fill out this form and send it back.) •

To: (insert the name, address and, where appropriate, the entrepreneur’s fax number and e-mail address)

• I / we (*) hereby revoke the contract concluded by me / us (*) for the purchase of the following goods (*) /

• Ordered on (*) / received on (*)

• name of the consumer (s)

• address of the consumer (s)

• Signature of the consumer (s) (only when notified on paper)

• date

_______________

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