Sample Withdrawal Form

Annex No. 1 – Model Withdrawal Form

Sievert Consulting s.r.o. IČO: 03675955 se sídlem: nám. sv. Václava 60/12, Stará Boleslav, 250 01 Brandýs nad Labem-Stará Boleslav zapsaná v obchodním rejstříku vedeném Městským soudem v Praze pod spisovou značkou C234970 kontaktní e-mail: info@treziqo.com telefon: +420 602 403 010 bankovní účet: 2803275250/2010

I hereby give notice that I withdraw from the agreement for the provision of the service / subscription:

Service name: Treziqo Date of conclusion of the agreement / order: __________ Consumer’s full name: __________ Consumer’s address: __________ Email used during registration: __________ Date: __________ Consumer’s signature (only if this form is submitted in paper form): __________