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Retraction form

Withdrawal Form


For the attention of Ms. Elodie ORTIZ, 124 Boulevard Romain Rolland 13010 Marseille France

E-mail address:



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) :

Consumer's address:




Consumers' signature (in case of presentation of the presented paper form): 

Date :






(*) Cross the useless mention.