For the attention of Ms. Elodie ORTIZ, 124 Boulevard Romain Rolland 13010 Marseille France
E-mail address: email@example.com
I/We (*) notify you by the present my/our (*) contract withdrawal dealing about the good's sale showed below:
Ordered on (*)/received on (*) :
Consumer's name(s) :
Consumers' signature (in case of presentation of the presented paper form):
(*) Cross the useless mention.