Withdrawal form

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

To: Firma Usługowa Jakub Stankiewicz, ul. Mikołaja Reja 31, 95-100 Zgierz, Poland, e-mail: [email protected]

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.