Sample withdrawal form

(If you wish to cancel the contract, please fill out this form and send it back to us)

To

hifidom Inh. Dieter Steinwedel, Konrad-Adenauer-Str. 20, 30823 Garbsen , Germany, e-mail address: shop@hifidom.com

I/we (*)* hereby revoke* the* contract concluded* by me/us (*) for the

Purchase of the following goods (*)/provision of the following service (*)

______________________________________________________

______________________________________________________

Ordered on (*) ____________ / received on (*) _________________

_______________________________________________________

Name of the consumer(s)

_______________________________________________________

Address of the consumer(s)

_______________________________________________________

Signature of the consumer(s) (only for notification on paper)

_________________________

Date

Delete as applicable.