Sample Withdrawal Form

To revoke the contract, please fill out this form and send it back to:

SEI DESIGN Home Textiles

Attn: Irina Richter Service Department

Sachsenhausener Str. 6D, 16515 Oranienburg

Email: service@sei-design.de

Fax: 03301/83926-26

I/we* hereby revoke the contract for the purchase of the following goods*/ the provision of the following service*:

Ordered on____________________ / received on______________

Name ________________________________________________

Order or customer number________________________________________________

Address ________________________________________________ ________________________________________________ Date _____________________________ Signature ______________________________ (only necessary for communication on paper)

• Delete as appropriate.