Declaration of exercising right of withdrawal / termination for payment

(to be filled in and sent back only in case of exercising right of withdrawal / termination)

Addressee: [1]

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I, the undersigned hereby declare that I exercise my right to withdraw the contract / right of termination in connection with contract of personal service provision:[2]

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Date of conclusion of the contract:

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Name of consumer:

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Address of consumer:

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Signature of consumer (necessary only in case of paper-based declaration):

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Dated: ………………………………… (place), ……………………(day) …………………(month), 20………………… (year)

[1] Write here the name, postal address, phone number and e-mail address of the company providing the service.

[2] Write here the service provided by the company based on the individual service agreement.