MODEL WITHDRAWAL FORM

If you want to withdrawl the contract, please fill out this form and send it back

To
Wombata
Maik Müller-Atzerodt
Blissestrasse 52
D-10713 Berlin

I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract of sale of the following goods (*)/for the provision of the following service (*),
_______________________________________________
_______________________________________________

Ordered on
_______________________ (*)
OR
received on
_______________________(*)

Name of consumer(s)
_________________________________

Address of consumer(s)
_________________________________
_________________________________
_________________________________

_________________________________
Date Signature of consumer(s)
only if this form is notified on paper

(*) Delete as appropriate

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