Withdrawal form

Cousins s.r.o., ID: 194 57 774

Nad údolím 209/80

147 00 Prague 4 – Hodkovičky

Notice of withdrawal from a contract concluded at a distance or away from the provider’s business premises

I hereby give notice that I withdraw from my contract for the purchase of the following goods /provision of the following services *:

………………………………………………………………………………………………………………………………

Contract number: ……………………………………

Date of contract /date of receipt of goods *:…………………………………………………………….

Full name: ……………………………………………………………………………………..

Address: …………………………………………………………………………………………………..

Connection point: ………………………………………………………………………………………………………………

Date: ……………………………………………….

…………………………………………………………………..

Signature 

Note: If you wish to withdraw from the contract, please fill out this form completely in the

blank sections and send it to the address above.

* delete as appropriate