Model withdrawal form

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

- To
G�nter Jaeger - Hardware & Elektronik
Karmelitenstra�e 1
97262 Hausen
Fax: 09367/988199
Email: info@chip-service.de

- I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract of sale of the following goods (*)/for the provision of the following service (*),

- Ordered on (*)/received on (*),

- Name of consumer(s),

- Address of consumer(s),

- Signature of consumer(s) (only if this form is notified on paper),

- Date

___________
(*) Delete as appropriate.