Model withdrawal form
(only complete and return this form if you wish to cancel the agreement)
Multicare-Centrum.nl Group
Marconistraat 80-E
2809PE Gouda
The Netherlands
email: info@multicare-centrum.nl
I/We* hereby inform you that I/we* terminate our agreement concerning the sale of the following products: [aanduiding product] *
the supply of the following digital content: [aanduiding digitale inhoud] *
the performance of the following service: [aanduiding dienst] , revokes/revoked
Ordered on/received on [datum bestelling bij diensten of ontvangst bij producten]
⦁ [Naam consumenten(en)]
⦁ [Adres consument(en)]
⦁ [Handtekening consument(en)] (only when this form is submitted on paper)
* Cross out what does not apply or fill in what applies.