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Withdrawal form

(Complete and return this form only if you wish to cancel the contract)

Pittemsestraat 58d
8850 Ardooie (Belgium)
Fax : +32 51 696 837

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(*).

Signature of consumer(s) (only if this form is notified on paper):

(*) Delete as appropriate.

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