Place, date
………………………………………
………………………………………
………………………………………
Name and surname of the consumer(s)
Address of the consumer(s)
Name and address of the entrepreneur
Statement
of withdrawal from a contract concluded at a distance
or outside the business premises
I/We (*)………………….……………hereby inform(*) you of my/our(*)
withdrawal from the contract for the sale of the following items(*) ………………………………..……
contract for the delivery of the following goods(*) …………………………………………………………..
contract for the performance of the following work/provision of the following
service(*)……………………………………………………………………..…………………………..
Date of conclusion of the contract 1 / receipt 2 (*)………………………………………..……………….
……………………………………………………
Signature of the consumer(s)
ul.Sikorskiego 21/3
11-400 Kętrzyn