WITHDRAWAL FORM SAMPLE
applies to the Consumer
NOTE: This form should be completed and sent back only if you wish to withdraw from the contract.
………………………., ……………………………….
…………………………………………
(Client's name and surname)
………………………………………..
…………………………………………
(Client's correspondence address)
…………………………………………
(phone number/contact email)
Mr./Mrs.*
RW-ZONE ROBERT WESOŁY
Kanclerska 16 Gortatowo
62-020 Swarzedz
robert@discushobby.com
WITHDRAWAL FROM A DISTANCE CONTRACT
I declare that I am withdrawing from the distance selling agreement concluded on ………………………………………… and concerning the purchase of the following goods ………………………………………………………………………………… for the price of ……………………………………
The goods were issued/received on …………………………………………………..
In connection with the above, I declare that I will return the goods immediately, no later than within fourteen days. Below I provide the data for the refund of the price of the goods, which should take place immediately, no later than within fourteen days.
…………………………………………………………………………..……………………
………………………………………………………………………………………..……
I am aware that the personal data provided by me will be processed by the Seller for purposes related to the execution of the withdrawal from the contract and the fulfillment of the related requests and in accordance with the principles specified in the relevant legal provisions. I know that I have the right to request from the data controller access to my data, its rectification, deletion or restriction of processing, or objection to processing, as well as the right to lodge a complaint with the supervisory authority.
……………………………………………………
(name, surname and signature of the Client,
if the form is sent in paper form)
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* – cross out what is not required