Withdrawal Form

(If you want to withdraw from the contract, please fill out this form and send it back)

Astradis Elektronik GmbH

Fraunhoferstr. 11a

82152 Planegg

Telefax: +49 (0) 89 89 505-100

info@astradis.com

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)

_________________________________

Date:________________

Signature of consumer(s):___________________________________________

(only if this form is notified on paper)

(*) Delete as appropriate