To
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)
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