Withdrawal form (legally required for Belgian web shops)

Withdrawal form
(only complete and return if you wish to cancel the agreement)

To AMAI Cafe
Address: Herenstraat 101, 3600 Genk, Belgium
E-mail: info@amai-cafe.be

I hereby give notice that I revoke our agreement regarding the purchase of the following goods:

• Ordered on [date]

• Received on [date]

• Consumer name:

• Consumer address:

• Signature (paper version only):

• Date:
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