If you wish to withdraw from the contract, please fill out this form and send it back.
— To [here, the name, address, and, if applicable, the fax number and email address of the business must be added by the provider]:
— I/we (*) hereby withdraw from the contract concluded by me/us (*) for the purchase of the following goods (*)/the provision of the following service (*):
— Ordered on (*)/received on (*)
— Name of the consumer(s)
— Address of the consumer(s)
— Signature of the consumer(s) (only if notified on paper)
— Date
(*) Delete as appropriate