"Please complete and return this form only if you wish to withdraw from the contract.
To the attention of [the professional hereby inserts his / her name, geographic address and, where available, his / her fax number and e-mail address]:
I / we (*) hereby notify you (*) that you have withdrawn from the contract for the sale of the property (*) / for the provision of services (*) below:
Ordered on (*) / received on (*):
If broken product, provide a picture of the package and the broken part:
Name of Consumer (s):
Address of Consumer (s):
Signature of the consumer (s) (only in the case of notification of this form on paper): ... '
(*) Delete as appropriate.