(If you want to withdraw from the contract, please fill out this form and send it back)

To

Daniel Laizure Brauereibedarf

Siemensstrasse 40

64850 Schaafheim

shop@amihopfen.com

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 (*),

_______________________________________________

_______________________________________________

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

Name of consumer(s) ______________________________________

Address of consumer(s)

_________________________________

_________________________________

_________________________________

Date:________________

Signature of consumer(s):___________________________________________

(only if this form is notified on paper)

(*) Delete as appropriate