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Sample cancellation form

(If you wish to cancel the contract, please complete and return this form).


To

Dr. Galva GmbH
Jungholzstrasse 7a
76726 Germersheim
Germany


I/we (*) hereby revoke the contract concluded by me/us (*) for the purchase of the following goods (*)/the provision of the following service (*)

Ordered on (*)/received on (*)

Name of the consumer(s)

Signature of consumer(s) (only in case of paper communication)

Date
------------

(*) Delete where inapplicable.