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WITHDRAWAL FORM

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

 

At

mme Mannheim Medizinelektronik UG (limited liability)

Eichelbergstr. 38

D-68163 Mannheim
 

Phone: +49 176 84318733

info@mme-partner.com

 

 

I/we (*) hereby revoke the contract concluded by me/us (*) for the purchase of the following goods (*) / the provision of the following service (*)

 

Bestellt am (*)                    _cc781905-5cde-3194 -bb3b-136bad5cf58d_           _cc781905 Received on (*)

 

Name of consumer(s) 

Address of consumer(s)

 

Date:

 

Signature of consumer(s):

(only if notification is on paper)

 

 

(*) Delete where not applicable

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