Appendix 4

Cancellation form

(Only fill out and return this form if you wish to cancel the contract)

— To ([Name and address of the store]), Telephone number: [Please provide telephone number], Fax number: [Please provide fax number], Email address: [Please provide email address], Fax number: [Please provide fax number], Email address: [Please provide email address].

— I/we (*) hereby notify that I/we (*) cancel my/our (*) purchase contract for the following goods (*)/for the provision of the following services

— Ordered on (*)/received on (*)

— Customer name

— Customer's address

— Customer signature (only if this form is delivered in paper form)

- Date

_______________

(*) Delete as appropriate.