Withdrawal form (NL)

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.Format: (+00) 0 00000000.
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
2 digit day, 2 digit month, 4 digit year
Should be Empty: