Cancellation form

(this form is completed and returned only if the right of withdrawal is exercised)

– To By Løth
Vosemosegyden 4
5250 Odense Sv-

I/we _______________ hereby announce that I/we wish to exercise the right of withdrawal in connection with my/our_________purchase agreement for the following goods ____________/delivery of the following services ______-

Ordered on ____/received on______

– Name of the consumer ___________
– The consumer's address ____________
– The consumer's signature____________________________