Withdrawal form

Withdrawal form model

 

 

 

For the attention of _______________________________________________________________

 

(Here you must insert the name of the employer, his full address and, if he has them, his fax number and his email address):

 

 

 

I hereby communicate / communicate (*) that I withdraw from me / we withdraw from our (*) sale contract of the following good / provision of the following service (*)

 

 

 

  • Name of the good / service (*): ______________________________________________

 

 

  • Ordered on (*): __ / __ / ____

 

 

  • Received on (*): __ / __ / ____

 

 

 

  • Name: ______________________________________________________________

 

(name of the consumer and user or consumers and users).

 

 

 

  • Address: _____________________________________________________________

 

(address of the consumer and user or consumers and users).

 

 

 

 

 

 

 

Signature of the consumer and user or consumers and users:

 

(only if this form is submitted on paper).

 

 

 

 

 

 

Date: __ / __ / ____

 

 

 

 

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