withdrawal form


form (Fill in and return this form only if you wish to withdraw from the contract) 



Chemin de l'etoquois 511 i 

7742 Herinnes, Belgium 


I/We (*)____________________ share(s) (*) you hereby give notice that I/we (*) revoke/revoke our agreement concerning the sale of the following goods/provision of the following service (*)____________________ (*) 

​​Ordered on (*)____________________ /Received on (*)____________________ 

Name/Names consumer(s) ____________________ 

Address consumer(s) ____________________ 

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

____________________, ____________________ 

Date ____________________ 
(*) ​​Strike out as appropriate

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