return form

Model form for revocation

(Complete this form only and return it if you want to revoke the agreement)

De Hollandse Klompenwinkel
Vrouwkensvaarsestraat 29
5165 NN Waspik
[email protected]

KVK NUMBER 61899062
VAT NUMBER NL189267744B01

- I / We (*) share / (*) hereby inform you that we / we (*) revoke / revoke our agreement on the sale of the following goods / delivery of the following service (*):


- Ordered on (DD-MM-YYYY):

- Order number:

- Received on (DD-MM-YYYY):


- Name / Name of consumer (s)


- Consumer Address (s):


- IBAN bank account:


- Signature of consumer (s) (only when this form is submitted on paper)


- Date (DD-MM-YYYY):


(*) Cross out what is not applicable.

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