Withdrawal form

WITHDRAWAL FORM

(Please complete and return this form only if you wish to withdraw from the contract.)
To the attention of:

[the professional inserts here his name, his geographical address and, when available, his fax number and his email address]:
I/we (*) hereby notify you of my/our (*) withdrawal from the contract for the sale of the goods (*)/for the provision of services (*) below:
Ordered on (*)/received on (*):
Name of consumer(s):
Address of the consumer(s):
Signature of the consumer(s) (only if this form is notified on paper):
Date :

(*) Delete what is unnecessary.