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(If you want to cancel the contract, please fill out this form and send it back.)

At
Malzmühle Dipl.-Ök. Stefan Welfonder
Saarstrasse 134
47198 Duisburg
Fax: 02845-9840553
stefaninpraxis@gmx.de


I / we (*) hereby revoke the contract concluded by me / us (*) for the purchase of the following goods (*) / the provision of the following service (*)
_______________________________________________
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Ordered on ___________________ (*) / received on _______________________ (*)

Name of the consumer (s) ______________________________________
Address of the consumer (s)
_________________________________
_________________________________
_________________________________

Date:________________

Signature of the consumer (s): ___________________________________________
(only with notification on paper)