Specimen - revocation form (PDF)

(If you wish to revoke the contract, please fill up this form and send it back to us.)

To

Dominika Scheer, Hauptfeld 3, 44369 Dortmund, Fax number: 0231-96988821, Email address: info~AT~madooma.com

I/we (*) herewith revoke the contract concluded by me/ us (*) regarding the purchase of the following  products (*)/   the provision of the following service (*)

Ordered on (*)/ received on (*)

Name of the consumer(s)

Address of the consumer(s)

Signature of the consumer(s) (only in case of a notification on paper)

Date

(*) Cross out the incorrect option.