WITHDRAWAL FORM FOR A DISTANCE CONTRACT
Customer Details
Full name: ....................................................................
Address: ............................................................................
Telephone / E-mail: ................................................................
Order number: .....................................................................
Bank account number: ...........................................................
Product Information
Product name: ....................................................................
Purchase date: .......................................................................
Value of the purchased product (including delivery costs): .............................................................................................
Date of receipt of the product: ...................................................
Customer's Declaration
In accordance with applicable law, I hereby withdraw from the distance contract. I therefore request a refund of the amount paid to the bank account specified above.
..............................................................................
Place and date: ...................................
Customer's signature: ..........................................................
KWELLA GABRIELYAN Sp. z o.o.
ul. Mickiewicza 36
32-626 Jawiszowice
Poland
VAT ID: PL 5492458723
REGON (National Business Registry Number): 386105050