I / we hereby cancel the contract concluded by me / us for the purchase of the following goods.

Details of the goods ______________________________________

Quantity | Item name Order date __________________________

Bestellnummer _________________________________________

Goods received at _______________________________________

Total price of the goods in € ________________________________

Your personal details:

First name, surname: _____________________________________

Street and house number _______________________________

Postcode/ Place: ___________________________________________

Date: _____________________________________________