Monopoel GmbH, Im Kleinfeld 9, 67227 Frankenthal, Fax: 0049-(0)6233-359853, E-Mail: info@monopoel.de

I/We hereby give notice that I/We withdraw my/our contract of sale of following goods/for the supply of the following service:

name and address of the consumer(s):

date and signature of the consumer(s) (only if this form is notified on paper)

What is the sum of 1 and 5 ?