Cancellation form

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

doorout.com GmbH & Co. KG

Frankfurter Str. 62

36043 Fulda

Telefax: +49(0)661-48019929

kundenservice@doorout.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