Withdrawal Complete and return this form only if you wish to withdraw from the contract. To Dieckmann Aroma Kaffee Jörg Hartwich Speicherhof 301 28217 Bremen Germany Phone: 0421/322675-0 E-Mail: mail@dieckmann-kaffee.de Withdrawal I/We hereby give notice that I/We withdraw from my/our contract of sale of the following goods/for the provision of the following service: Note: Delete as appropriate. Ordered on Received on * Name of consumer(s) Gender Mr Miss/Ms/Mrs Firstname * Lastname * Address of consumer(s) No./Street Postcode/ZIP Town Country Your e-mail address, to immediately confirm the receipt of the withdrawal Your e-mail * Withdrawal date Send withdrawal * required
