Withdrawal Form

Withdrawal Form

(If you want to withdraw from your oder, please print and complete this form, then send it to us)

Att. / An

Douro & Porto / Vinum Mundi

Eric van Crombrugge

Osnabrücker Weg 27

33378 Rheda-Wiedenbrück

E-Mail: info@vinum-mundi.com

Herewith I cancel the contract over following goods

_______________________________________________

Ordered on ___________________ (*)/ received on _______________________(*)

Name of consumer ______________________________________

Address of consumer _________________________________

_________________________________

_________ _____________________________________________________

Date Signature