Withdrawal form template

WITHDRAWAL DECLARATION TEMPLATE

Date: ……………………

DECLARATION OF WITHDRAWAL FROM THE CONTRACT

I, the undersigned:
Name and surname: …………………………………………
Address: ……………………………………………………
E-mail: ……………………………………………………
Telephone: ……………………………………………………

I hereby inform you about my withdrawal from the distance sales contract regarding:

Order number: ……………………………………
Date of order placement: ……………………………
Date of receipt of goods: ………………………………
Name of the product/products: ………………………………
……………………………………………………………

I am requesting a refund to:
☐ the same payment method as in the order
or (optional)
☐ bank account: ……………………………………

Signature (if sent in paper form): …………………………

Seller details:
iSeller – Daryna Vodolazkina
ul. Żurawia 32/34, apt. 29, 00-515 Warsaw
e-mail: info@iseller.com.pl , tel. +48 732 554 136