SAMPLE WITHDRAWAL FORM FOR CONTRACTS CONCLUDED REMOTELY AND CONTRACTS CONCLUDED OUTSIDE THE TRADER’S BUSINESS PREMISES

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(Fill in and send this form only if you wish to withdraw from a contract concluded remotely or from a contract concluded outside the trader’s business premises.)

– To: Mária Lazarová, Žitavská 175/17, 95197, Žitavany, Slovak Republic

– I/We* hereby give notice that I/we* withdraw from my/our* contract for the supply of the following goods/services: ..............

– Order date / Date of receipt* ..............

– Name(s) of consumer(s)* ..............

– Address of consumer(s)* ..............

– Signature of consumer(s)* (only if this form is submitted on paper) ..............

– Date ..............

• Delete as appropriate