Model withdrawal form

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

- To
AIMPLIFY Distribution Inc.
Talstr. 12
99706 Sondershausen
Germany
E-Mail: sales@aimplify.com
Fax: +49 3632 828234

- 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 form is notified on paper),
- Date


___________
(*) Delete as appropriate.