Division B Model withdrawal form

To [here the trader’s name, geographical address and, where available, his fax number and e-mail address are to be inserted by the trader]:

I/We^f1 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/received on,

Name of consumer(s),

Address of consumer(s),

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

Date