Model Withdrawal Form

MODEL WITHDRAWAL FORM

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

To: Amplla a.s., Poličská 1823, 539 01 Hlinsko, Czech Republic, e-mail: [email protected]

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),
• Order number (optional, to help us find your order),
• Signature of consumer(s) (only if this form is notified on paper),
• Date

(\) Delete as appropriate.*