Withdrawal form

Withdrawal form

 

MODEL WITHDRAWAL FROM THE CONTRACT

(this form should be completed and returned only if you wish to withdraw from the contract)

Addressed: _________________________________________________________________

email: _________________________________

I hereby inform about my withdrawal from the Agreement for the provision of the Service provided as part of the akhealthcaucus.org Website

the date of conclusion of the contract ______________________________________________________________

first and last name of the Consumer (s) ______________________________________________________

_______________________________________________________________________________

Consumer (s) login on the akhealthcaucus.org Website ______________________________________

Signature of the Consumer (s) ____________________________________________________________

Data ___________________________________________________________________________