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

— To:

— 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 (*),

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— Ordered on (*)/received on (*),

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— Name of consumer(s),

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— Address of consumer(s),

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— Signature of consumer(s) (only if this form is notified on paper),

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— Fecha

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(*) Delete as appropriate.