Sample cancellation form

At
Micompan engineering
Kleinburgforder Str. 11A
D-26655 Westerstede;

I/we hereby revoke the contract concluded by me/us(*) for the purchase of the following goods(s):

Item number:

_________________________________________________________________________


Item name:

_________________________________________________________________________


Ordered on/received on(*): ___________________________


Consumer's first and last name:

_________________________________________________________________________


Anschrift des Verbrauchers:

_________________________________________________________________________


Date, signature:

_________________________________________________________________________


(*) Please delete what is not applicable