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(Should you wish to withdraw from the contract, please fill out this form and return it to us.) — To Yvonne Waska 43 rue Lucien Sampaix 75010 Paris. — I/We (*) hereby withdraw from the contract concluded by me/us (*) governing the sale of the following goods: — Ordered on/received on (*): — Name of the consumer(s): — Address of the consumer(s): — Consumer's signature (only in the case of notification on paper) Date : (*) Delete as applicable
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