Sample cancellation form
To: Empion GmbH,
Postal address: Empion GmbH, Dircksenstraße 47, 10178 Berlin, Germany
Email address: widerruf@empion.de
I/we (*) hereby revoke the contract concluded by me/us (*) for the provision of the following service (*)
Ordered on (*)/received on (*)
Name of consumer(s):
Address of consumer(s):
Signature (only in case of paper notification):
Date:
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(*) Delete where inapplicable