Right of Withdrawal

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Annex I: Model withdrawal form

Model withdrawal form

(complete and return this form only if you wish to revoke the agreement)

  • To: [ name entrepreneur]

[ geographic address entrepreneur]

[ fax number entrepreneur, if available]

[ e-mail address or electronic address of entrepreneur]

  • I/We* hereby inform/share* you, that I/We* hereby terminate our agreement regarding the sale of the following products: [aanduiding product]*

the provision of the following digital content: [aanduiding digitale inhoud]* the provision of the following service: [aanduiding dienst]*, revoke/revoke*

  • Ordered on*/received on* [datum bestelling bij diensten of ontvangst bij producten]
  • [Naam consumenten(en)]
  • [Adres consument(en)]
  • [Handtekening consument(en)] (only if this form is submitted on paper)

* Cross out what does not apply or fill in what is applicable.

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