SAMPLE WITHDRAWAL FORM
(If you want to cancel the contract, please fill out and return this form).
To
Ampereshop
c/o Hagemann Systems Solutions GmbH
Hauptstr. 74a
42349 Wuppertal
Fax: 02 02 / 9 46 09 07 11
E-Mail: info@ampereshop.com
I/we (*) hereby revoke the contract concluded by me/us (*) for the purchase of the following goods (*) / the provision of the following service (*)
_______________________________________________
Ordered on ___________________ (*)/received on _______________________(*)
Name of the consumer(s)______________________________________
Address of the consumer(s)
_________________________________
_________________________________
_________ _____________________________________________________
Date Signature of consumer(s) (only in case of notification on paper)
(*) Delete where inapplicable