Model Withdrawal Form

(complete and return this form only if you wish to withdraw from the contract)

Fundacja Klub Fundacji Centaurus, registered office in Wrocław
ul. Skarbowców 23A/BUD.B3
53-025 Wrocław, Poland

– I/We(*) hereby give notice that I/we(*) withdraw from my/our(*) contract of sale of the following goods(*)

Order number: ……………………………………………………………………………..

Invoice/receipt number: ……………………………………………………………………………..

Ordered on(*)/received on(*) …………………………………………………………………………….

Name of consumer(s) …………………………………………………………………………….

Address of consumer(s) …………………………………………………………………………….

Signature of consumer(s) (only if this form is submitted on paper)

Date ……………………………………………………………………………

Please refund the amount due to bank account no.:

(*) Delete as appropriate.