Withdrawal form for a purchase made on www.ikitex.fr

To be printed, completed and sent by email to florian@ikitex.fr

To the attention of Exopump SAS, 910 route du corbet, 38480 Le Pont de Beauvoisin – FRANCE.

I hereby notify you of my withdrawal from the contract for the sale of the following goods:

Ordered on :   ___ /___ /____

Received on : ___ /___ /____

Invoice number (received by email when the order was shipped) : _______________

Customer’s Name :    _____________________________________

Customer’s address :    _______________________________________________ _____________________________________________________________

Customer’s signature (only in case of notification of this form on paper):

Date : ___ /___ /____