MODEL WITHDRAWAL FORM

If you wish to withdraw from the contract, please complete this form and return it.
Use of this form is optional.

To:
Hamidreza Arghiyani / SchadstoffCheck
Lohstr. 187
47798 Krefeld
Germany
Email: Arghiyani@gmx.de

I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract
for the provision of the following service:

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Ordered on (*) / Contract concluded on (*):

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Name of consumer(s):

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Address of consumer(s):

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Signature of consumer(s) (only if this form is submitted on paper):

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Date:

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(*) Delete as appropriate.