Model withdrawal form

(complete and return this form only if you wish to withdraw from the contract)


To:  
 
Belecon GmbH
Christoph Bettag
Steinfurt 9
52222 Stolberg
Germany
 
E-Mail: contact@form-2-function.com  
 
 
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 (*) / 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