Model Withdrawal Form

(Complete and return this form only if you wish to withdraw from the contract.)

To:
Fabian Both
Werderstraße 64
76137 Karlsruhe
Germany
Email: contact@golemry.com

- I/We hereby give notice that I/We withdraw from my/our contract for 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 sent on paper):

  ______________________________________________________________

- Date: _______________________________________________________