MODEL WITHDRAWAL FORM

Complete and return this form only if you wish to withdraw from the contract.
You may use another clear statement instead of this form.

To: Hesra, devcalcedo@gmail.com

I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract
for the provision of the following service: Hesra.

Ordered on: ____________________

Name of consumer(s): ____________________

Address of consumer(s): ____________________

Account email or purchase reference (optional): ____________________

Signature of consumer(s) (only if this form is sent on paper): ____________________

Date: ____________________

(*) Delete as appropriate.