Withdrawal form

(only fill in and return this form if you wish to withdraw from the agreement)

— Modelcarmate Veenendaalkade 512 2547 BC The Hague info@modelcarmate.com 06-801 288 91

— I/We (*) hereby inform you that I/we (*) revoke our agreement concerning the sale of the following goods/provision of the following service (*):

— Ordered on (DD-MM-YYYY) : — Order number :

— Received on (DD-MM-YYYY):

— Name(s) of consumer(s)

— Consumer(s) address:

— IBAN Account number:

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

— Datum(DD-MM-YYYY):

(*) Cross out what does not apply.