Withdrawal Form for a Distance Contract and an Off-Premises Contract

• To: SOLUQA Technology s. r. o., 1. mája 2598/43, Pezinok 902 01, Slovak Republic
• I/we* hereby notify that I/we* withdraw from the contract for the supply or provision of the following product: ..............
• Order date/Receipt date* ..............
• Consumer's full name(s)* ..............
• Consumer's address* ..............
• Consumer's signature(s)* (if this form is submitted in physical form) ..............
• Date ..............
• If you wish to receive a refund via bank transfer, please provide your account number................................................................................................................

* Cross out what does not apply