Withdrawal form

(complete and return this form only if you wish to revoke the agreement)

To:

Steco Steigers
Elerweg 57
3680 Maaseik (Belgium)
Mobile: +32 (0) 496 532 330
E-mail: [email protected]

I hereby inform you that I revoke our agreement regarding the sale of the following goods:

Order number:           ORD.....................

Date of order:             ... / ... / ....

Date of receipt:           ... / ... / ....

Your name: ......................................................................................................

......................................................................................................

Your address: ......................................................................................................

......................................................................................................

......................................................................................................

Your refund account number: ............................................................

Signature (required only if this form is submitted on paper):

Date:           ... / ... / ....