Standard Agreement Withdrawal Application Form:
(please only fill in and send this form if you wish to withdraw from the agreement)
To: _______________________________________
I/we hereby notify that I/we wish to withdraw from my/our agreement for the purchase of the following services:
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Sent/Received – …………………………………………………………………………………………
The consumer's name/consumers' names: ……………………………………………………………………………………………….
The consumer's address/consumers' addresses: …………………………………………………………………………………………………
The consumer's signature/consumers' signatures: ……………………………………………….
(only when you submit a paper agreement withdrawal application form)
Date: ……………………………………………
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