Withdrawal form

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

— ToModelcarmateVeenendaalkade 5122547 BC The Hagueinfo@modelcarmate.com06-801 288 91

— I/We (*) hereby inform you that I/we (*) revoke my/our (*) agreement regarding the sale of the following goods (*)/provision of the following service (*):

— Ordered on (DD-MM-YYYY) : — Order number :

— Received on (DD-MM-YYYY):

— Name(s) of consumer(s)

— Consumer(s) address:

— IBAN Account number:

— Signature of consumer(s) (only when this form is submitted on paper)

— Datum(DD-MM-YYYY):

(*) Cross out what does not apply.