MODEL WITHDRAWAL FORM

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

For the attention of Thermo Life customer service, 771 boulevard du grand terme, 30133 Les Angles:

I/we (*) hereby notify you of my/our (*) withdrawal from the contract relating to the sale of goods (*)/for the provision of services (*) below:

Ordered on (*)/received on (*):

Name of consumer(s):

Address of consumer(s):

Signature of the consumer(s) (only in case of notification of this form on paper):

Date :

(*) Strike out the useless mention.