MODEL WITHDRAWAL FORM

Complete and send this form only if you wish to withdraw from the contract.

Addressee: BIOMEFIX s.r.o., Pernerova 727/40a, Karlín, 186 00 Praha 8, Czech Republic, e-mail: info@biomefix.eu

I hereby give notice that I withdraw from the contract for the purchase of the following goods / provision of the following service:

Order number:

Date ordered / date received:

Consumer’s name and surname:

Consumer’s address:

E-mail / telephone:

Account number for refund (optional; only if the payment cannot be refunded by the original method and the consumer agrees to this method):

Reason for withdrawal (optional):

Date:

Consumer’s signature (only if this form is submitted on paper):

Instructions

The withdrawal notice must be sent no later than the last day of the fourteen-day period. Send or hand over the goods no later than 14 days from withdrawal. The consumer bears the direct costs of returning the goods, unless otherwise agreed. Please package the goods well; do not send them cash on delivery unless otherwise agreed with the Seller.