Cancellation form

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

To:

Maria Habeck Autoteile GmbH
Zum Hohen Moor 6
27729 Lübberstedt
Germany

Fax: +49 4793 - 957797
E-mail: mhteile@gmx.de

I/we (*) hereby revoke the contract

concluded by me/us (*) for the purchase of the following goods (*) the provision of the following service (*)
……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………

ordered on (*) ………………………………………………………………………………

received on (*) ………………………………………………………………………………

Invoice number ………………………………………………………………………………

Name of the consumer(s) ……..…………………………………………………………….

Address of the consumer(s)
…………………………………………………………………. …………………………………………………………………. ………………………………………………………………….

Telephone number ………………………………………………………………….

Date, signature of consumer(s) (only if notification is on paper)

______________________________________

(*) Delete as appropriate.