Optional cancellation request form

To: Louise Mason, 6 Eastwood Rd, Leicester, LE2 8DB

e-mail: [email protected]


I/We [*] hereby give notice that I/We [*] cancel my/our [*] contract of sale of

the following goods [*]/for the supply of the following service [*],


Ordered on [*]/received on [*],


Name of consumer(s),


Address of consumer(s),


Signature of consumer(s) (only if this form is notified on paper),




[*] Delete as appropriate.

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