Note: This is a translation for your information. The German version alone is legally authoritative: German version

Model withdrawal form

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

To
Electronicx GmbH
Hindenburgstr. 37A
74389 Cleebronn
Germany
E-mail: [email protected]

I/We (*) hereby withdraw from 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 consumer(s): ____________________

Address of consumer(s): ____________________

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

Date: ____________________

(*) Delete as appropriate.