Contract withdrawal

Order number:: * Order number:

Name, buyer name:: * Name, buyer name:

Date of ordering the goods: * Date of ordering the goods

Date of receipt of the goods: * Date of receipt of the goods

Buyer's home address:: * Buyer's home address:

Buyer Email:: * Buyer Email:

Buyer Phone:: * Buyer Phone:

I request a refund to my account number:: * I request a refund to my account number: