Withdrawal

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 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)