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			MODEL WITHDRAWAL FORM 
			French Consumer Code - art. Annex to article R221-1 Created by Decree no. 2016-884 of 29 June 2016 
			Please complete and return this form only if you wish to withdraw from the above contract. 
			For the attention of: 
			Name of agency:

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						<td>{% textarea_tag name=&quot;64fe2fbc&quot; data_width=&quot;70&quot; rows=&quot;1&quot; data_label=&quot;Nom de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom de l&#39;agence&quot; data_textarea_value=&quot;INFO_CLIENT_enseigne&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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Full address:

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						<td>{% textarea_tag name=&quot;d345c4f5&quot; data_width=&quot;70&quot; rows=&quot;1&quot; data_label=&quot;Adresse de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse&quot; data_textarea_value=&quot;INFO_CLIENT_adresse&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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Tel :

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						<td>{% textarea_tag name=&quot;5d9ed1ee&quot; data_width=&quot;40&quot; rows=&quot;1&quot; data_label=&quot;T&eacute;l&eacute;phone de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;T&eacute;l&eacute;phone agence&quot; data_textarea_value=&quot;INFO_CLIENT_telephone&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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Email :

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						<td>{% textarea_tag name=&quot;9b4ce0de&quot; data_width=&quot;70&quot; rows=&quot;1&quot; data_label=&quot;E-mail de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;E-mail agence&quot; data_textarea_value=&quot;INFO_CLIENT_email&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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I/we hereby notify you of my/our withdrawal from the contract 
			for the following property (delete as appropriate): 
			..................................................................................................................................... 
			.................................................................................................................................... 
			Ordered on:&nbsp;.............................................. 
			Name of consumer(s): 
			.................................................................................................................................... 
			..................................................................................................................................... 
			Address name of consumer(s): 
			................................................................................................................................... 
			................................................................................................................................... 
			Date :&nbsp;............................... 
			Signature of the consumer(s),&nbsp;only if this form is submitted on paper. 
			Conditions :

<ul>
				<li>Complete and sign this form.</li>
				<li>Use the agency address above.</li>
				<li style="text-align: justify;">Dispatch it no later than the fourteenth day from the day after the order was placed or, if this period normally expires on a Saturday, 
				Sunday or public or bank holiday, on the next working day.</li>
				<li>You may notify your decision to withdraw, for example, by post or e-mail to the agency.</li>
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