Withdrawal Form

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

To PrimaHost von Nikolaj Gurezkij, Rosenweg 36, 04209 Leipzig, Germany, Email: moc.gn-tsohamirp@ofni
I/We (*) hereby give notice that I/We (*) withdraw from my/ our (*)
contract 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.