Fill in and send this form if you wish to withdraw from the purchase contract to the seller:

program health as, Drobného 27, 841 01 Bratislava

ID number:

I hereby withdraw from the purchase contract for the goods:

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Order number:

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Date of receipt of goods:

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Name and surname of the consumer:

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Address of the consumer:

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Account to which the refund should be made:

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IBAN:

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Consumer's signature:

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A date:

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The place:

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