MODEL WITHDRAWAL FORM FOR A DISTANCE PURCHASE CONTRACT

Complete this form only if you wish to withdraw from the contract. You may also submit another clear statement.

Recipient: Mix idėjos, UAB
Email: info@mixidejos.lt
Seller address: Telšių g. 82, Plungė
Return address: Vaižganto g. 90, Plungė

I hereby give notice that I withdraw from the contract of sale for the following goods:

Product(s) and quantity:
Order number:
Order date:
Date goods received:
Buyer full name:
Buyer address:
Buyer contact details:
Date:
Signature (only if this form is submitted on paper):