Sample revocation form

(If you want to cancel the contract, please fill in this form and send it back.)

An Cologne Energy | Mr. Oliver Rothweiler, Neusser Strasse 422C, 50733 Cologne,, Fax: 0221-9924574

I/we (*) hereby revoke the contract for the purchase of the following goods (*)/performance of the following service (*) concluded by me/us (*)

Ordered on (*)/received on (*)

Name of the consumer (s)

Address of the consumer (s)

Signature of the consumer (s) (only for communication on paper)

Date - Date

(*) Delete as applicable.