Model withdrawal form

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Complete and return this form only if you wish to withdraw from the contract. Please note that for the unique assignment and quick processing it would be very helpful if you also specify your email address used to register for our service.

Model withdrawal form

To Interdate S.A., Lisa18 Customer Service, 13 rue du Commerce, L-1351 Luxembourg, Luxembourg:

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): ______________________________

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

Date: __________________________

___________________________________________________________________________________

(*) Delete as appropriate

 

Optional specification:

Your email address used for registration: _________________________________