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Main page » Model withdrawal form

Withdrawal

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

To

Rudolf Dietze Uhrmacher- und Goldschmiedebedarf
Rudolf Dietze
Wachauerstraße 19
04416 Markkleeberg
Germany

Fax: 03413380499
E-Mail: info@rudolf-dietze.de

Withdrawal

Note: Delete as appropriate.

Ordered on

Received on

Name of consumer(s)

Gender

Mr Miss/Ms/Mrs

Firstname

Lastname

Address of consumer(s)

No./Street

Postcode/ZIP / Town

Country

Your e-mail address, to immediately confirm the receipt of the withdrawal

Your e-mail

Withdrawal date

Privacy I have read the privacy notice.

* required