Revocation Form

(If you want to withdrawl the contract, please fill out this form and send it back)

To

Ursula Dymowski

Alte Landstr. 14

47877 Willich

[email protected]

I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract of sale of the following goods (*)/for the provision of the following service (*),

_______________________________________________

_______________________________________________

Ordered on ___________________ (*)/received on _______________________(*)

Name of consumer(s) ______________________________________

Address of consumer(s)

_________________________________

_________________________________

_________________________________

Date:________________

Signature of consumer(s):___________________________________________

(only if this form is notified on paper)


(*) Delete as appropriate