Standard withdrawal form
This form is only used if your right of withdrawal is applicable.

Gammel Kongevej 163
Postboks 454
1850 Frederiksberg C

I hereby give notice that I wish to make use of my right of withdrawal applicable with my purchase agreement for the following product:

Ordered date: _______________________________ Recieved date: _______________________________

Consumer name: ______________________________________________________________________

Consumer adress: ___________________________________________________________________

Consumer signature: _________________________________________ Date: _________________