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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