An / To: OmniX digital trade GmbH
Kastellstraße 31–35, Raum 76, 47546 Kalkar, Deutschland
customer@omnix-gmbh.de

I hereby withdraw from my contract for the purchase of the following goods:

Goods / order reference:
Ordered on / received on:
Consumer name:
Consumer address:
Date:
Signature (paper notices only):