Withdrawal form
Place, date
………………………………
Addressee:
Kostiantyn Honcharenko
ul. Stefana Batorego 24/15
81-366 Gdynia
NIP: PL5862416623
Telefon: +48734638148
Mail: kostantingoncarenko7@gmail.com
Customer data: (name and surname, address, e-mail address, telephone number)* : ………………………………………………………………………………………………….……………………….…….
………………………………………………………………………………………………………………………………..
DECLARATION OF WITHDRAWAL FROM A CONTRACT CONCLUDED AT A DISTANCE
OR OUTSIDE THE BUSINESS PREMISES
I hereby declare that, exercising my rights, and observing the 14-day deadline, I withdraw from the agreement concluded on** ..................................... regarding the purchase/delivery of goods*** (description of goods, order number/invoice number, reason for withdrawal)* .........................................................................................................,
…………………………………………………………………………………………………………………………….………….delivered to me on ........................................................ **
…………………………………………
Date and signature
(if the declaration is made in writing)
* The customer is required to provide an address, other data to be completed is optional
** Please indicate one of the dates: purchase or delivery
*** Cross out as appropriate