Withdrawal form (BE)

Withdrawal form

You only need to complete this form if you wish to withdraw the agreement.
Name*

First nameLast name
Address details*

Street name + house number

Street Address Line 2

ResidenceState / Province

Postal codeCountry
Phone number*
Enter a valid phone number.
Email address*
example@example.com
IBAN number*
Order details*

I hereby notify you that I am revoking the contract relating to the sale of the goods listed below:*

Reason for withdrawal*
If you wish to recall an electric bike, please include a clear photo of the mileage:
Signature
Date*

DayMonthYear
Should be Empty: