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Return form

This form is to be completed and sent only if you wish to withdraw form the contract.

To the attention of IRINA KHÄ - LINDEN SA, located at 12 rue du Pot d'Or, 4000 Liège - +32 4 221 21 35 - shop@irina-kha.com

I hereby give notice that I withdraw from my contract of sale of the following item(s) :

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Ordered on (date) :

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Name of the client :

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Address of the client :

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Date and signature of the client :

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