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Patented cable lug insulation


Withdrawal Form

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