To

Miriam Rohde

Brummerskamp 49A

22457 Hamburg

Germany

Revocation of my purchase / contract* (please strikethrough anything that doesn´t apply)

Dear Mrs. Rohde,

I / we hereby revoke the contract concluded by me / us for the purchase of the following goods / the provision of the following service :

Ordered on :

Received on :

My / Our name/s is / are :

My / Our address is :

Signature/s of the buyer/s :   (Only in case of notification on paper)

Place : Date :