Pattern of form of revocation


(If you want to cancel the contract, please fill out this form and send it back.)
At
Teevino.de
Kerstin Schramm
Kirchstr. 11
65326 Aarbergen
Fax: 06120-508525
E-mail: kontakt@teevino.de
Hereby give notice that (s) I / we (*) from my / us (*) concluded contract for the purchase of the following products (*) /
the provision of the following service (*)
_______________________________________________
_______________________________________________
Appointed on ___________________ (*) / received on _______________________ (*)
Name of person / consumer (s) ______________________________________
Address of person / consumer (s)
_________________________________
_________________________________
_________________________________
______________________________________________________________
date - Signature / consumer (s) (with message on paper)
Emphasize -------- (*) Delete