withdrawal form

Cancellation form

If you wish to cancel this contract, please complete and submit this form.

pilker-discount GmbH
Clara-Viebig-Str. 10
07545 Gera
Deutschland
Fax: +49 365 7127779
E-Mail: info@pilker-discount.de

I/We (*) hereby give notice that I/We (*) cancel my/our (*) contract of sale of the following goods (*) /for the supply of the following service (*),

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Ordered on (*) ____________ / received 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 notified on paper)

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Date

(*) Delete as appropriate