Model withdrawal form

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


Walberg Urban Electrics GmbH

Alter Wandrahm 6

20457 Hamburg


Fax: +49 40 300 87 119

Model withdrawal form

— I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract of sale of the
following goods (*)/for the provision of the following service (*),

— Ordered on (*)/received on (*)

— Name of consumer(s),
— Address of consumer(s),

— Signature of consumer(s) (only if this formis notified on paper),
— Date

(*) Delete as appropriate.