Model withdrawal form

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

To United Movement, trading as Faro Costa, Poolsterstraat 6, 6133VP Sittard, Netherlands, info@farocosta.com:

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

• Ordered on () / received on ():
• Name of consumer(s):
• Address of consumer(s):
• Signature of consumer(s) (only if this form is notified on paper):
• Date:

(*) Delete as appropriate.