I/We[*] hereby give notice that I/We [*] cancel my/our [*] contract of sale of the following goods [*] [for the supply of the following service [*], Ordered on [*]/received on [*]______________________(date received)
Name of consumer(s):
Address of consumer(s):
Signature of consumer(s) (only if this form is notified on paper)
[*] Delete as appropriate.