(You only have to complete and send this form if you wish to withdraw from the contract/purchase)

I hereby inform you that I withdraw from the process of the following purchase:

Reference of the purchase / and where appropriate, specific items with respect to which the withdrawal occurs:

Date of formalization of the purchase:

Name of the consumer and user :

Address and contact information of the consumer and user:

Signature of the consumer and user (only if this form is submitted on paper)

Date :