Appendix 1 : Withdrawal form

Please complete and return this form only if you wish to withdraw from the contract.

For the attention of: WEINK

Address: [to be completed]

Telephone: [to be completed]

Email address: [to be completed]

I hereby notify you of my withdrawal from the contract for the services: ________________

If the refund is to be made in a form other than the original means of payment:

I expressly agree that the refund may be made by [to be completed].

Registration on the WEINK platform on [to be completed].

Customer name: ___________________

Customer address: __________________

Customer signature: __________________

(only in case of notification of this form on paper)

Date : __________________