Cancellation Form

To:

Posthofbrug 6/8 Bus 5/148, 2600 Berchem, Belgium

E-Mail: [email protected]

I/We (*) hereby give notice that I/We (*) cancel 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)
- Signature of consumer(s) (only if this form is notified on paper)
- Date

(*) Delete as appropriate