Please complete just this form and send it back if you wish to withdraw from the agreement.
— To BELION / Les Savons Gourmands, Chaussée de Liège 297/2, 5100 Jambes, Belgium, les.savons.gourmands@gmail.com:
— I/We (*) hereby inform you that I/we (*) withdraw from the agreement concerning the sale of the following goods/performance of the following service (*):
— Ordered on (*)/Received on (*)
— Name(s) of consumer(s)
— Address of consumer(s)
— Signature(s) of consumer(s) (only if paper version of this form is lodged)
— Date
(*) Delete as appropriate.