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MODEL WITHDRAWAL FORM
Please complete and return this form only if you wish to withdraw from the contract.
(*) Strike out what does not apply.
To: Version5 s.a.
Chemin de la Maison du Roi, 32 A
1380 Lasne – Belgium
info@edouardjanssens.com
I/We (*) hereby inform you that I/we (*) withdraw from my/our (*) contract of sale of the following goods/provision of services (*)
- Ordered on (*)/Received on (*): ………………………………………………………………………………………
- Name/Names consumer(s): ………………………………………………………………………………………
- Address consumer(s): ………………………………………………………………………………………….
- Signature of consumer(s) (only applicable when this form is submitted in paper)
- Date: ………………………
Article 5 - Price
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