Withdrawal Form

Model Form for Dissolution / Revocation
Fill out and return this form only if you wish to dissolve / revoke the agreement.
To
Foundation Young Dogs
Attn: Hanma
Textielplein 43, 5046RJ Tilburg, Netherlands
I hereby inform you, the student company mentioned above, that I wish to revoke our agreement regarding the sale of the following products:
o ____________________________________________
o ____________________________________________
o ____________________________________________
Ordered on _____________ and Received on ______________
Your Name (Name of the Consumer)

Your Address (Address of the Consumer)


Your Bank Account Number (Bank Account Number of the Consumer) for refund of the purchase amount
NL _ ____ ______________
Account in the name of: _______________
Date Signature of the consumer(s)
[only required if this form is submitted on paper]

(*) The address of the relevant student company is in the order confirmation sent with the ordered item.