Withdrawal/Cancellation declaration

Withdrawal/Cancellation declaration -- sample

(fill in and return only if you wish to withdraw from the contract)

Addressee [insert the name, postal address and e-mail address of the company]:

The undersigned(s) declare(s) that I/we exercise my/our right of withdrawal/cancellation in respect of the contract for the purchase of the following good(s) or the provision of the following service(s):

Date of conclusion of the contract or acceptance:

Name of consumer(s):

Address of consumer(s):

Signature of the consumer(s) (in case of paper declaration only):

Dated