Standard form for withdrawal

Complete this form and return it only when you want to revoke the agreement. 

De Groene Drogist
Linieweg 46
3831WB  LEUSDEN
THE NETHERLANDS 

I hereby inform you that I wish to revoke our agreement on the sale of the following products: [specification of the  product]*

-            Ordered on* [date of ordering the services or receiving products]*

-            [Consumer’s name]

-            [Consumer’s address]

-            [Consumer’s signature] (only when this form is submitted on paper)

*) Delete and/or complete where appropriate.