Model Withdrawal Form

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

To: Mike's Dive Store

I/We hereby give notice that I/We withdraw from my/our contract of sale of the following goods:

Order Number: _______________________

Goods Ordered: _______________________

Date Ordered: _______________________

Date Received: _______________________

Customer Name: _______________________

Customer Address: _______________________

Signature (if submitted on paper): _______________________

Date: _______________________