Model Withdrawal Form

(If you wish to withdraw from the contract, please complete this form and return it to us.)

To:

[Company name] [Address] [Email address]

I/We (*) hereby withdraw from the contract concluded by me/us (*) for the purchase of the following goods:

Ordered on (*) / received on (*):

Name of consumer(s):

Address of consumer(s):

Signature of consumer(s) (only if this form is submitted on paper):

Date:

(*) Delete as appropriate.