Withdrawal Form or Contract Cancellation Form
Withdrawal from Purchase Agreement
Sender (Buyer):
Full Name / Company Name: ……………………………………………..
Address / Place of Business / Company Headquarters: ……………………………………………..
Phone: ……………………………………………..
E-mail: ……………………………………………..
Order Number: ……………………………………………..
Date of Contract Conclusion: ……………………………………………..
Date of Receipt of Goods: ……………………………………………..
Reason for Withdrawal from the Purchase Agreement (optional):
………………………………………………………………………………
………………………………………………………………………………
Bank Account Number for Refund:
……………………………………………..
I hereby declare that I am withdrawing from the purchase agreement No. …………………………………., concluded on …………………………………., and
request a refund to the above-mentioned bank account.
In …………………………………., on …………………………
Signature of Buyer (required only if the form is submitted in printed form)