To
I/we (*) hereby revoke the contract concluded by me/us (*) for the purchase of the following goods (*) / the provision of the following service (*)
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Ordered on _______________________ (*)/received on _______________________(*)
Name of the consumer(s) ___________________________________________________
Address of the consumer(s)
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_________________________________
_________________________________
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Date Signature of the consumer(s) (only for paper notification)
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(*) Delete as appropriate