(Only fill out and return this form if you wish to cancel the contract)

— To ([company name and address]), telephone number: [please provide telephone number], fax number: [please provide fax number], email address: [please provide email address], fax number: [please provide fax number], email address: [please provide email address].

— I/we (*) hereby notify that I/we (*) cancel my/our (*) contract for the provision of the following services

— Ordered on (*)/received on (*)

— Name of the customer(s)

— Address of the customer(s)

— Signature of the customer (only if this form is delivered in paper form)

- Date

_______________

(*) Delete if not applicable.