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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 of the product, if applicable order number and price)

Ordered on:
Received on:

name and address of the consumer(s):
Name of consumer(s):
Address of consumer(s):

date and signature of the consumer(s) (only if this form is notified on paper)
What is the sum of 4 and 1 ?
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