I hereby declare that, exercising my statutory right, I withdraw from the contract concluded on the date of …………………………………….. concerning the purchase/delivery of the following item(s)*:
Product description, order number/invoice number, reason for withdrawal*: ………………………………………………………………………………………………………. ………………………………………………………………………………………………………. Delivered to me on: ……………………………………..
………………………………………………. Date and signature (if the statement is submitted in paper form)
*Providing your postal address is mandatory. Other fields are optional but recommended for efficient processing. ** Please indicate one of the two dates: purchase or delivery. *** Cross out items that do not apply.
