Terms and conditions

Terms and Conditions – Fleeck.com

Table of contents:

Article 1 – Definitions

Article 2 – Identity of the entrepreneur

Article 3 – Applicability

Article 4 – The offer

Article 5 – The agreement

Article 6 – Liability

Article 7 – Right of withdrawal

Article 8 – 30-day money-back guarantee

Article 9 – Obligations of the consumer during the reflection period

Article 10 – Exercise of the right of withdrawal by the consumer and costs thereof

Article 11 – Obligations of the entrepreneur in case of withdrawal

Article 12 – Exclusion of right of withdrawal

Article 13 – The price

Article 14 – Compliance and extra warranty

Article 15 – Delivery and implementation

Article 16 – Duration transactions: duration, cancellation and extension

Article 17 – Payment

Article 18 – Complaints procedure

Article 19 – Disputes

Article 20 – Additional or different stipulations

Article 1 – Definitions

In these conditions the following terms have the following meanings:

1. Additional agreement: an agreement whereby the consumer acquires products, digital content and / or services in connection with a distance contract and these goods, digital content and / or services are supplied by the entrepreneur or by a third party on the basis of an agreement between that third party and the entrepreneur;
2. Reflection period: the period within which the consumer can exercise his right of withdrawal;
3. Consumer: the natural person who does not act for purposes related to his trade, business, craft or profession;
4. Day: calendar day;
5. Digital content: data that is produced and supplied in digital form;
6. Duration agreement: an agreement that extends to the regular delivery of goods, services and / or digital content during a certain period;
7. Durable data carrier: any tool – including e-mail – that enables the consumer or entrepreneur to store information that is addressed to him personally in a way that future consultation or use during a period that is tailored to the purpose what the information is for and which allows unaltered reproduction of the stored information;
8. Right of withdrawal: the possibility for the consumer to withdraw from the distance contract within the cooling-off period;
9. Entrepreneur: the natural or legal person who offers products, (access to) digital content and / or services to consumers at a distance;
10. Distance contract: an agreement that is concluded between the entrepreneur and the consumer in the context of an organized system for distance selling of products, digital content and / or services, whereby up to and including the conclusion of the agreement, exclusive or joint use is made of one or more techniques for distance communication;
11. Model withdrawal form: the European model withdrawal form included in Appendix I of these conditions. Annex I does not have to be made available if the consumer has no right of withdrawal with regard to his order;
12. Technology for distance communication: means that can be used to conclude an agreement, without the consumer and entrepreneur having to meet in the same room at the same time.

Article 2 – Identity of the entrepreneurs

[Entrepreneur name] Thomas van der Wee
[Business address]; Van Nelleweg 1; 3044 BC ROTTERDAM 
[Visiting address, if different from the business address]; 
[Name of entrepreneur] Floris Wulffele 
[Business address]; Van Nelleweg 1; 3044 BC ROTTERDAM   

Telephone number: 010-3070397

Email address: [email protected]

Chamber of Commerce number: 71487719

VAT identification number: NL858735325B01

If the activity of the entrepreneur is subject to a relevant licensing system: the details of the supervisory authority.

If the entrepreneur practices a regulated profession:

  • the professional association or organization to which he is affiliated;
  • the professional title, the place in the EU or the European Economic Area where it was awarded;
  • a reference to the professional rules that apply in the Netherlands and instructions where and how these professional rules are accessible.

Article 3 – Applicability

  1. These general terms and conditions apply to every offer from the entrepreneur and to every distance contract concluded between the entrepreneur and the consumer.
  2. Before the distance contract is concluded, the text of these general terms and conditions will be made available to the consumer. If this is not reasonably possible, before the distance contract is concluded, the entrepreneur will indicate how the general terms and conditions can be viewed by the entrepreneur and that they will be sent free of charge at the request of the consumer.
  3. If the distance contract is concluded electronically, notwithstanding the previous paragraph and before the distance contract is concluded, the text of these general terms and conditions can be made available to the consumer electronically in such a way that the consumer can can be easily stored on a durable data carrier. If this is not reasonably possible, before the distance contract is concluded, it will be indicated where the general terms and conditions can be consulted electronically and that they will be sent free of charge electronically or otherwise at the request of the consumer.
  4. In the event that specific product or service conditions apply in addition to these general terms and conditions, the second and third paragraphs apply mutatis mutandis and the consumer can always invoke the applicable provision that is most favorable to him in the event of conflicting conditions. .

Article 4 – The offer  

  1. If an offer has a limited period of validity or is made subject to conditions, this will be explicitly stated in the offer.
  2. The offer contains a complete and accurate description of the offered products, digital content and / or services. The description is sufficiently detailed to allow a proper assessment of the offer by the consumer. If the entrepreneur uses images, they are a true representation of the offered products, services and / or digital content. Obvious mistakes or obvious errors in the offer do not bind the entrepreneur.
  3. Each offer contains such information that it is clear to the consumer what rights and obligations are attached to the acceptance of the offer.

Article 5 – The agreement

  1. The agreement is concluded, subject to the provisions of paragraph 4, when the consumer accepts the offer and meets the corresponding conditions.
  2. If the consumer has accepted the offer electronically, the entrepreneur will immediately confirm receipt of acceptance of the offer electronically. As long as the receipt of this acceptance has not been confirmed by the entrepreneur, the consumer can dissolve the agreement.
  3. If the agreement is concluded electronically, the entrepreneur will take appropriate technical and organizational measures to protect the electronic transfer of data and he will ensure a safe web environment. If the consumer can pay electronically, the entrepreneur will observe appropriate security measures.
  4. The entrepreneur can, within legal frameworks, inform himself whether the consumer can meet his payment obligations, as well as all those facts and factors that are important for a responsible conclusion of the distance contract. If, on the basis of this investigation, the entrepreneur has good reasons not to enter into the agreement, he is entitled to refuse an order or request, stating reasons, or to attach special conditions to the execution.
  5. At the latest upon delivery of the product, service or digital content to the consumer, the entrepreneur will send the following information, in writing or in such a way that it can be stored by the consumer in an accessible manner on a durable medium:
  6. the visiting address of the establishment of the entrepreneur where the consumer can go with complaints;
  7. the conditions under which and the manner in which the consumer can exercise the right of withdrawal, or a clear statement regarding the exclusion of the right of withdrawal;
  8. information about guarantees and existing after-sales service;
  9. the price including all taxes on the product, service or digital content; insofar as applicable the delivery costs; and the method of payment, delivery or implementation of the distance contract;
  10. the requirements for terminating the agreement if the agreement has a duration of more than one year or is indefinite;
  11. if the consumer has a right of withdrawal, the model withdrawal form.

In the event of an extended transaction, the provision in the previous paragraph only applies to the first delivery.

Article 6 – Liability

Fleeck.com performs its task as can be expected of a company in its industry. as prescribed by the NZA and makes every effort to achieve the best possible result, but does not accept any liability for damage, including loss of life, personal injury, consequential damage, trading loss, loss of profits and / or stagnation damage of acts or omissions of itself, its staff or third parties engaged by it, except insofar as there is intent and / or deliberate recklessness on the part of its partners, its management and / or its management staff.

2. Fleeck.com is in particular not liable in the event that (afterwards, it turns out to the other party) that certain costs related to the services of fleeck.com are not reimbursed (for example by insurance companies). In addition, fleeck.com is in particular not liable for lost, damaged and / or stolen property of the other party or of any other person on the fleeck.com company site.

3. Notwithstanding the provisions of paragraph 1 of this article, the liability of fleeck.com -for whatever reason- is limited to the amount of the net price of the agreement concerned, hereinafter to be understood; the purchase amount of the purchased products. Fulfillment of this guarantee is the only and full compensation.

4. Without prejudice to the provisions of the previous paragraph of this article, the user is never obliged to pay damages that exceed the insured amount.

5. If fleeck.com cannot successfully rely on paragraphs 1 and / or 3 of this article due to the circumstances of the case and / or the nature of the damage and / or existing legislation, fleeck.com will never be obliged to to compensation which is more than the insured amount.

6. In all cases, the period within which fleeck.com can be held liable for compensation for damage is limited to 12 months after the transaction and / or purchase.

7. The other party loses its rights vis-à-vis fleeck.com and is liable for all damage and indemnifies fleeck.com against any claim by third parties with regard to compensation if and insofar as:

A. the aforementioned damage is caused by an act or omission of the other party in violation of the instructions and / or advice of fleeck.com;

B. the aforementioned damage has arisen due to incompetent and / or with instructions from fleeck.com contrary to the use and / or inexpert storage (storage) of any delivered goods;

C. the aforementioned damage is caused by errors or inaccuracies in data (including medical reports, doctor’s statements, information from governments and / or other information), all in the broadest sense provided to fleeck.com by and on behalf of the other party and / or prescribed.

8. The other party indemnifies fleeck.com against claims from third parties arising from its activities and for which it is not liable under these conditions.

Article 7 – Right of withdrawal

With products:

  1. The consumer can terminate an agreement with regard to the purchase of a product during a reflection period of at least 14 days without giving any reason. The entrepreneur may ask the consumer about the reason for withdrawal, but not oblige him to state his reason (s).
  2. The reflection period referred to in paragraph 1 commences on the day after the consumer, or a third party designated by the consumer in advance, who is not the carrier, has received the product, or:
  3. if the consumer has ordered several products in the same order: the day on which the consumer, or a third party designated by him, has received the last product. The entrepreneur may, if he has clearly informed the consumer about this prior to the ordering process, refuse an order for several products with a different delivery time.
  4. if the delivery of a product consists of several shipments or parts: the day on which the consumer, or a third party designated by him, has received the last shipment or the last part;
  5. for contracts for regular delivery of products during a certain period: the day on which the consumer, or a third party designated by him, has received the first product.

For services and digital content that is not supplied on a tangible medium:

  1. The consumer can terminate a service agreement and an agreement for the supply of digital content that has not been delivered on a tangible medium for at least 14 days without giving any reason. The entrepreneur may ask the consumer about the reason for withdrawal, but not oblige him to state his reason (s).
  2. The reflection period referred to in paragraph 3 starts on the day following the conclusion of the agreement.

Extended reflection period for products, services and digital content that has not been delivered on a tangible medium if you do not inform about the right of withdrawal:

  1. If the entrepreneur has not provided the consumer with the legally required information about the right of withdrawal or the model withdrawal form, the reflection period ends twelve months after the end of the original reflection period determined in accordance with the previous paragraphs of this article.
  2. If the entrepreneur has provided the information referred to in the previous paragraph to the consumer within twelve months after the effective date of the original reflection period, the reflection period expires 14 days after the day on which the consumer received that information.

Article 8 – 30-day money-back guarantee

We are absolutely confident in providing the best at-home teeth whitening and oral hygiene products. That’s why we have a 100% results or money back guarantee should your teeth not become at least 2 shades whiter. Products to which this guarantee applies can be recognized by the notification of the guarantee on the product page.

In the unlikely event that your teeth are not at least 2 shades whiter by using Fleeck products, see below.

To qualify for our money back guarantee, simply follow the instructions below:

1. Take a clear photo * of your teeth before using our products.
2. Use our products for 6 consecutive days exactly as instructed in the enclosed manual.
3. Take a clear photo every day * after you have completed all instructions and make sure the photos have a clear time and date stamp.
4. Send to [email protected] your order number and your 7 photos together with a photo of the products used within 30 days of receipt. 5. After our approval, you will receive a notification and you can return the products, with the exception of the toothbrush and the tongue scraper. 

You have 30 days from the received date to process a money back guarantee request. We will then refund the purchase amount minus the shipping costs to the desired account number within 10 working days.

Applications that do not meet these criteria will not be approved for refund.

* Make sure to take your front and all 7 other photos in similar lighting conditions to display accurate results. All before and after photos must also contain valid date and time stamps.

Article 9 – Obligations of the consumer during the reflection period  

  1. During the reflection period, the consumer will handle the product and packaging with care. He will only unpack or use the product to the extent necessary to determine the nature, characteristics and functioning of the product. The basic principle here is that the consumer may only handle and inspect the product as he should in a shop.
  2. The consumer is only liable for depreciation of the product that is the result of a way of handling the product that goes further than allowed in paragraph 1.
  3. The consumer is not liable for any diminished value of the product if the entrepreneur has not provided him with all legally required information about the right of withdrawal before or at the conclusion of the agreement.

Article 10 – Exercise of the right of withdrawal by the consumer and costs thereof  

  1. If the consumer makes use of his right of withdrawal, he will report this to the entrepreneur within the cooling-off period by means of the model withdrawal form or in another unambiguous manner.
  2. As soon as possible, but within 14 days from the day following the notification referred to in paragraph 1, the consumer returns the product, or hands it over to (an authorized representative of) the entrepreneur. This is not necessary if the entrepreneur has offered to collect the product himself. The consumer has in any case observed the return period if he returns the product before the cooling-off period has expired.
  3. The consumer returns the product with all accessories supplied, if reasonably possible in the original condition and packaging, and in accordance with the reasonable and clear instructions provided by the entrepreneur.
  4. The risk and the burden of proof for the correct and timely exercise of the right of withdrawal lies with the consumer.
  5. In case of return, the consumer bears the direct costs of returning the product. A possible exception to this is if the entrepreneur indicates to bear the costs himself. In that case, the consumer does not have to bear the costs for return.
  6. If the consumer withdraws after first expressly requesting that the provision of the service or the supply of gas, water or electricity that have not been made ready for sale commences in a limited volume or certain quantity, commences during the cooling-off period, the consumer is the entrepreneur. amount due that is proportionate to that part of the obligation that the entrepreneur has fulfilled at the time of withdrawal, compared to the full fulfillment of the obligation.
  7. The consumer does not bear any costs for the performance of services or the supply of water, gas or electricity, which are not made ready for sale in a limited volume or quantity, or for the supply of district heating, if:
  8. the entrepreneur has not provided the consumer with the legally required information about the right of withdrawal, the cost reimbursement in case of withdrawal or the model withdrawal form, or;
  9. the consumer has not explicitly requested the commencement of the performance of the service or the supply of gas, water, electricity or district heating during the reflection period.
  10. The consumer does not bear any costs for the full or partial delivery of digital content that is not supplied on a tangible medium if:
  11. prior to delivery, he has not expressly agreed to commence performance of the agreement before the end of the cooling-off period;
  12. he has not acknowledged that he loses his right of withdrawal when giving his consent; or
  13. the entrepreneur has failed to confirm this statement from the consumer.
  14. If the consumer makes use of his right of withdrawal, all additional contracts will be terminated by operation of law.

Article 11 – Obligations of the entrepreneur in case of withdrawal

  1. If the entrepreneur makes the notification of withdrawal by the consumer electronically possible, he will immediately send a confirmation of receipt after receipt of this notification.
  2. The entrepreneur reimburses all payments from the consumer, including any delivery costs charged by the entrepreneur for the returned product, without delay but within 14 days following the day on which the consumer reports the withdrawal. Unless the entrepreneur offers to collect the product himself, he may wait with repayment until he has received the product or until the consumer demonstrates that he has returned the product, whichever is earlier.
  3. The entrepreneur uses the same payment method that the consumer has used for repayment, unless the consumer agrees to a different method. The refund is free of charge for the consumer.
  4. If the consumer has opted for a more expensive method of delivery than the cheapest standard delivery, the entrepreneur does not have to reimburse the additional costs for the more expensive method.

Article 12 – Exclusion of right of withdrawal  

The entrepreneur can exclude the following products and services from the right of withdrawal, but only if the entrepreneur has clearly stated this in the offer, at least in time for the conclusion of the agreement:

  1. Products or services whose price is subject to fluctuations in the financial market over which the entrepreneur has no influence and which can occur within the withdrawal period;
  2. Agreements concluded during a public auction. A public auction means a sales method in which products, digital content and / or services are offered by the entrepreneur to the consumer who is personally present or who is given the opportunity to be personally present at the auction, under the supervision of an auctioneer, and whereby the successful bidder is obliged to purchase the products, digital content and / or services;
  3. Service contracts, after full performance of the service, but only if:
  4. execution has begun with the express prior consent of the consumer; and
  5. the consumer has declared that he loses his right of withdrawal as soon as the entrepreneur has fully executed the agreement;
  6. Package travel as referred to in Article 7: 500 BW and passenger transport contracts;
  7. Service contracts for the provision of accommodation, if the contract provides for a specific date or period of performance and other than for residential purposes, freight transport, car rental services and catering;
  8. Agreements related to leisure activities, if the agreement provides for a specific date or period of implementation;
  9. Products manufactured according to consumer specifications, which are not prefabricated and which are manufactured on the basis of an individual choice or decision of the consumer, or which are clearly intended for a specific person;
  10. Products that spoil quickly or have a limited shelf life;
  11. Sealed products that are not suitable for return for reasons of health protection or hygiene and of which the seal has been broken after delivery;
  12. Products that, by their nature, are irrevocably mixed with other products;
  13. Alcoholic drinks, the price of which was agreed when the contract was concluded, but the delivery of which can only take place after 30 days, and the actual value of which depends on market fluctuations over which the entrepreneur has no influence;
  14. Sealed audio, video recordings and computer software, of which the seal was broken after delivery;
  15. Newspapers, magazines or magazines, with the exception of subscriptions to these;
  16. The delivery of digital content other than on a tangible medium, but only if:
  17. execution has begun with the express prior consent of the consumer; and
  18. the consumer has declared that he will lose his right of withdrawal.

Article 13 – The price  

  1. During the period of validity stated in the offer, the prices of the products and / or services offered will not be increased, except for price changes as a result of changes in VAT rates.
  2. Contrary to the previous paragraph, the entrepreneur can offer products or services whose prices are subject to fluctuations in the financial market and over which the entrepreneur has no influence, with variable prices. This link to fluctuations and the fact that any stated prices are target prices are stated in the offer.
  3. Price increases within 3 months after the conclusion of the agreement are allowed at all times.
  4. The prices stated in the offer of products or services are exclusive of VAT.

Article 14 – Fulfillment of the agreement and additional guarantee  

  1. The entrepreneur guarantees that the products and / or services comply with the agreement, the specifications stated in the offer, the reasonable requirements of reliability and / or usability and the legal provisions existing on the date of the conclusion of the agreement and / or government regulations. If agreed, the entrepreneur also guarantees that the product is suitable for other than normal use.
  2. An additional guarantee provided by the entrepreneur, his supplier, manufacturer or importer never limits the legal rights and claims that the consumer can assert against the entrepreneur under the agreement if the entrepreneur has failed to fulfill his part of the agreement.
  3. An extra guarantee is understood to mean any obligation of the entrepreneur, his supplier, importer or producer in which he grants the consumer certain rights or claims that go beyond what he is legally obliged to do in case he has failed to fulfill his part of the agreement. .

Article 15 – Delivery and implementation  

  1. The entrepreneur will take the greatest possible care when receiving and implementing orders for products and when assessing applications for the provision of services.
  2. The place of delivery is the address that the consumer has made known to the entrepreneur.
  3. With due observance of what is stated in article 4 of these general terms and conditions, the entrepreneur will execute accepted orders expeditiously, but at the latest within 30 days, unless another delivery term has been agreed. If delivery is delayed, or if an order cannot or only partially be executed, the consumer will be notified of this no later than 30 days after placing the order.
    Exceeding any delivery term does not give the other party the right to compensation, but only the right to cancel the order or to dissolve the agreement.
  4. After dissolution in accordance with the previous paragraph, the entrepreneur will immediately refund the amount that the consumer has paid.
  5. The risk of damage and / or loss of products rests with the entrepreneur until the moment of delivery to the consumer or a pre-designated and announced representative to the entrepreneur, unless expressly agreed otherwise.

Article 16 – Duration transactions: duration, cancellation and extension  

Cancellation:

  1. The consumer can terminate an agreement that has been concluded for an indefinite period and which extends to the regular delivery of products (including electricity) or services, subject to the agreed cancellation rules and a notice period of no more than one month.
  2. The consumer can terminate a contract that has been concluded for a definite period and that extends to the regular delivery of products (including electricity) or services, at any time towards the end of the fixed term, with due observance of the agreed cancellation rules and a notice period of at least top one month.
  3. The consumer can the agreements mentioned in the previous paragraphs:
    • cancel at any time and not be limited to cancellation at a specific time or in a specific period;
    • at least cancel in the same way as they have been entered into by him;
    • always cancel with the same notice period as the entrepreneur has stipulated for himself.

Extension:

  1. A contract that has been concluded for a definite period and that extends to the regular delivery of products (including electricity) or services may not be automatically extended or renewed for a fixed period. 
  2. Contrary to the previous paragraph, a contract that has been entered into for a definite period and that extends to the regular delivery of daily news and weekly newspapers and magazines may be tacitly renewed for a limited period of up to three months if the consumer has this extended contract for a can terminate the extension with a notice period of up to one month.
  3. A contract that has been concluded for a definite period and that extends to the regular delivery of products or services may only be extended tacitly for an indefinite period if the consumer can cancel at any time with a notice period of no more than one month. The notice period is a maximum of three months if the agreement extends to the regular, but less than once a month, delivery of daily, news and weekly newspapers and magazines.
  4. An agreement with a limited duration to the regular delivery of daily, news and weekly newspapers and magazines (trial or introductory subscription) is not tacitly continued and ends automatically after the trial or introductory period.

Expensive:

  1. If an agreement has a duration of more than one year, the consumer may cancel the agreement at any time with a notice period of no more than one month, unless the reasonableness and fairness oppose cancellation before the end of the agreed duration.

Article 17 – Payment  

  1. Unless otherwise stipulated in the agreement or additional conditions, the amounts owed by the consumer must be paid within 14 days after the start of the cooling-off period, or in the absence of a cooling-off period within 14 days after the conclusion of the agreement. In the event of an agreement to provide a service, this period commences on the day after the consumer has received the confirmation of the agreement.
  2. When selling products to consumers, the consumer may never be obliged to pay more than 50% in advance in general terms and conditions. When prepayment has been stipulated, the consumer cannot assert any rights regarding the execution of the order or service (s) concerned before the stipulated prepayment has taken place.
  3. The consumer has the duty to immediately report inaccuracies in payment details provided or stated to the entrepreneur.
  4. If the consumer does not meet his payment obligation (s) in time, after he has been informed by the entrepreneur of the late payment and the entrepreneur has granted the consumer a period of 14 days to still meet his payment obligations, after failure to pay within this 14-day period, the statutory interest is due on the amount still owed and the entrepreneur is entitled to charge the extrajudicial collection costs incurred by him. These collection costs amount to a maximum of: 15% on outstanding amounts up to € 2,500; 10% on the next € 2,500 and 5% on the next € 5,000 with a minimum of € 40. The entrepreneur can deviate from the aforementioned amounts and percentages for the benefit of the consumer.

Article 18 – Complaints procedure  

  1. The entrepreneur has a well-publicized complaints procedure and handles the complaint in accordance with this complaints procedure.
  2. Complaints about the performance of the agreement must be submitted fully and clearly described to the entrepreneur within a reasonable time after the consumer has discovered the defects.
  3. Complaints submitted to the entrepreneur will be answered within a period of 14 days from the date of receipt. If a complaint requires a foreseeable longer processing time, the entrepreneur will reply within the period of 14 days with a notice of receipt and an indication when the consumer can expect a more detailed answer.
  4. In case of complaints, a consumer must first turn to the entrepreneur. If the web shop is affiliated with the WebwinkelKeur Foundation and complaints that cannot be resolved by mutual agreement, the consumer must turn to the WebwinkelKeur Foundation ( webwinkelkeur.nl ), which will mediate free of charge. Check whether this webshop has a current membership via https://www.webwinkelkeur.nl/leden/ . If a solution is still not reached, the consumer has the option of having his complaint handled by the independent disputes committee appointed by Stichting WebwinkelKeur, the decision of which is binding and both the entrepreneur and the consumer agree to this binding decision. Submitting a dispute to this disputes committee involves costs that must be paid by the consumer to the relevant committee. It is also possible to report complaints via the European ODR platform ( http://ec.europa.eu/odr ). 
  5. The consumer must in any case give the entrepreneur 4 weeks to resolve the complaint by mutual agreement. After this period, a dispute arises that is subject to the dispute settlement.

Article 19 – Disputes  

  1. Only Dutch law applies to agreements between the entrepreneur and the consumer to which these general terms and conditions apply.

Article 20 – Additional or different stipulations  

Additional or deviating provisions from these general terms and conditions may not be to the detriment of the consumer and must be recorded in writing or in such a way that they can be stored by the consumer in an accessible manner on a durable medium.

Appendix I: Model withdrawal form

Model withdrawal form

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

[To: Fleeck.com] 

[Provide 52, 3032GA ROTTERDAM]

[010-3075427]

[email protected] ] 

  • I / We * share / share * hereby that I / we * our agreement

the sale of the following products: [designation product] *

the delivery of the following digital content: [digital content description] *

the provision of the following service: [designation of service] *,

revoked / revoked *

  • Ordered on * / received on * [order date with services or receipt with product (s)]
  • [Name of consumer (s)]
  • [Consumer (s) address]
  • [Consumer (s) signature] (only if this form is submitted on paper)

* Cross out what does not apply or fill in what applies.