Withdrawal form

SAMPLE CANCELLATION FORM

(If you want to cancel the contract, please fill out this form and send it back.)

Mike Breitenborn

Pappelallee 8

04821 Brandis

Fax: 034292/632664

mail: bike-mike@t-online.de

I / we (*) hereby cancel the contract concluded by me / us (*) for the purchase of the following goods (*) / the provision of the following service (*)

_______________________________________________

Ordered on ___________________ (*) / received on _______________________ (*)

Name of the consumer (s)

______________________________________

Address of the consumer (s)

_________________________________

Date:________________

Signature of the consumer (s): ___________________________________________

(only for notification on paper)

(*) Delete where inapplicable