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Withdrawal Form

To the attention of:

STARCK GALLERY
Carrer Martin i Soler, 5
Elche BusinessElche
03203 Elche
Spain
Email: info@starck-gallery.com

I hereby give notice of my withdrawal from the contract for the sale of the property listed below:

Order No.: ______________________
Order Date: ______________________
Receipt Date: ______________________

Customer Name: ______________________
Customer Address: ______________________
____________________________________
____________________________________

Product(s) in question:
____________________________________
____________________________________
____________________________________

Reason for return (if applicable) — optional:
____________________________________
____________________________________

Date: ______________________

Customer signature
—only for paper mailings:

______________________

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