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]

Telefoon	Betsy	0031(0)638961072
	Jan	0031(0)628953179

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.