TERMS OF THE ONLINE STORE  VICHEMIC.PL

TABLE OF CONTENTS:

GENERAL PROVISIONS
ELECTRONIC SERVICES IN THE ONLINE STORE
CONDITIONS FOR CONCLUDING THE SALES CONTRACT
METHODS AND DEADLINES FOR PAYMENT FOR THE PRODUCT
COST, METHODS AND DELIVERY DATE AND PRODUCT RECEIPT
PRODUCT COMPLAINT
EXTRAJUDICIAL WAYS OF EXAMINING COMPLAINTS AND INVESTIGATING CLAIMS AND RULES OF ACCESS TO THESE PROCEDURES
RIGHT TO WITHDRAW FROM THE CONTRACT
PROVISIONS CONCERNING ENTREPRENEURS
FINAL PROVISIONS
MODEL WITHDRAWAL FROM THE CONTRACT
The www.vichemic.pl online store cares for the rights of consumers. The consumer may not waive the rights conferred on him by the Consumer Rights Act. Contract provisions less favorable to the consumer than the provisions of the Act on Consumer Rights are invalid, and in their place the provisions of the Act on Consumer Rights apply. Therefore, the provisions of these Regulations are not intended to exclude or limit any consumer rights they enjoy under mandatory provisions of law, and any possible doubts should be explained in favor of the consumer. In the event of any non-compliance of the provisions of these Regulations with the above provisions, priority is given to these provisions and should be applied.
GENERAL PROVISIONS
The Online Store available at the internet address www.vichemic.pl is run by Norbert Szmajdewicz conducting business activity under the name Vichemic Industries Norbert Szmajdewicz entered in the Central Register and Information on Economic Activity of the Republic of Poland kept by the minister competent for economy, having: address of place of business and delivery address: Daniszewska 24C lok. 15, 03-230 Warsaw, NIP 5242810030, REGON 365583438, e-mail address: kontakt@vichemic.pl, phone number: 507251675.
These Regulations are addressed to both consumers and entrepreneurs using the Online Store, unless a given provision of the Regulations provides otherwise and is addressed only to consumers or to entrepreneurs.
The administrator of personal data processed in the Online Store in connection with the implementation of the provisions of these Regulations is the Seller. Personal data is processed for the purposes, for a period and based on the basis and principles indicated in the privacy policy published on the Online Store website. The privacy policy contains primarily rules regarding the processing of personal data by the Administrator in the Online Store, including the basics, purposes and period of personal data processing and the rights of data subjects, as well as information on the use of cookies and analytical tools in the Online Store. Using the Online Store, including making purchases, is voluntary. Similarly, the provision of personal data related to the Service User or Customer using the Online Store is voluntary, subject to the exceptions indicated in the privacy policy
(conclusion of the contract and statutory obligations of the Seller).
definitions:

WORKING DAY – one day from Monday to Friday, excluding public holidays.

REGISTRATION FORM – a form available in the Online Store that allows you to create an Account.

ORDER FORM – Electronic Service, an interactive form available in the Online Store enabling placing an Order, in particular by adding Products to the electronic basket and determining the terms of the Sales Agreement, including the method of delivery and payment.

CUSTOMER – (1) a natural person with full legal capacity, and in the cases provided for by generally applicable provisions also a natural person with limited legal capacity; (2) legal entity; or (3) an organizational unit without legal personality, which the law confers legal capacity – which has concluded or intends to conclude a Sales Agreement with the Seller.

CIVIL CODE – the Civil Code Act of April 23, 1964 (Journal of Laws of 1964 No. 16, item 93, as amended).

ACCOUNT – Electronic Service, marked with an individual name (login) and password provided by the Service Recipient, a set of resources in the Service Provider’s IT system, in which the data provided by the Service Recipient and information about his Orders in the Online Store are collected.

NEWSLETTER – Electronic Service, an electronic distribution service provided by the Service Provider via e-mail, which allows all Service Users using it to automatically receive from the Service Provider cyclical content of subsequent editions of the newsletter containing information about Products, new products and promotions in the Online Store.

PRODUCT – a movable item available in the Online Store that is the subject of the Sales Agreement between the Customer and the Seller.

REGULATIONS – these Regulations of the Online Store.

ONLINE STORE – the Service Provider’s online store available at the Internet address: www.vichemic.pl.

DEALER; SERVICE PROVIDER – NORBERT SZMAJDEWICZ conducting business activity under the company Vichemic Norbert Szmajdewicz entered into the Central Register and Information on Economic Activity of the Republic of Poland kept by the minister competent for economy, having: address of place of business and address for delivery: Daniszewska 24C lok. 15, 03-230 Warsaw, NIP 5242810030, REGON 365583438, e-mail address: kontakt@vichemic.pl, phone number: 507251675.

SALES AGREEMENT – a Product sales contract concluded or concluded between the Customer and the Seller via the Online Store.

ELECTRONIC SERVICE – a service provided electronically by the Service Provider to the Service User via the Online Store.

SERVICE USER – (1) a natural person with full legal capacity, and in the cases provided for by generally applicable provisions also a natural person with limited legal capacity; (2) legal entity; or (3) an organizational unit without legal personality, which the law confers legal capacity – using or intending to use the Electronic Service.

CONSUMER RIGHTS ACT, ACT – the Act of 30 May 2014 on consumer rights (Journal of Laws of 2014, item 827, as amended)

ORDER – Customer’s declaration of intent submitted via the Order Form and directly aiming at concluding the Product Sales Agreement with the Seller.

ELECTRONIC SERVICES IN THE ONLINE STORE
The following Electronic Services are available in the Online Store: Account, Order Form and Newsletter.

Account – the use of the Account is possible after completing a total of three consecutive steps by the Service User – (1) completing the Registration Form, (2) clicking the “Create Account” field and (3) confirming the desire to create an Account by clicking the confirmation link sent automatically to the address provided email. In the Registration Form, it is necessary for the Service Recipient to provide the following Service Recipient’s data: name and surname / company name, address (street, house / flat number, zip code, city, country), e-mail address, contact telephone number and password. In the case of Customers who are not consumers, it is also necessary to provide the company name and tax identification number.

The Electronic Account service is provided free of charge for an indefinite period. The Service Recipient has the option, at any time and without giving a reason, to remove the Account (resignation from the Account) by sending an appropriate request to the Service Provider, in particular via e-mail to the following address: kontakt@vichemic.pl or in writing to the address: Daniszewska 24C lok. 15, 03-230 Warsaw.

Order Form – the use of the Order Form begins when the Customer adds the first Product to the electronic basket in the Online Store. Placing an Order takes place after execution by Kli
entering data consistent with the facts. The Service Recipient is forbidden to provide illegal content.
Complaint procedure regarding Electronic Services:

Complaints related to the provision of Electronic Services by the Service Provider and other complaints related to the operation of the Online Store (excluding the complaint procedure of the Product, which was indicated in point 6 of the Regulations) The Service Recipient may submit, for example:

in writing to the address: Daniszewska 24C lok. 15, 03-230 Warsaw;

in electronic form via e-mail to the following address: kontakt@vichemic.pl.

It is recommended that the Service Recipient in the complaint description: (1) information and circumstances regarding the subject of the complaint, in particular the type and date of irregularities; (2) the Customer’s request; and (3) contact details of the person submitting the complaint – this will facilitate and accelerate the consideration of the complaint by the Service Provider. The requirements given in the previous sentence are only recommendations and do not affect the effectiveness of complaints submitted without the recommended description of the complaint.

The Service Provider shall respond to the complaint immediately, not later than within 14 calendar days from the date of its submission.

CONDITIONS FOR CONCLUDING THE SALES CONTRACT
The conclusion of the Sales Agreement between the Customer and the Seller takes place after the Customer has placed the Order using the Order Form in the Online Store in accordance with point 2.1.2 of the Regulations.
The Product price shown on the Online Store website is given in Polish zlotys and includes taxes. About the total price including taxes of the Product being the subject of the Order, as well as about the delivery costs (including charges for transport, delivery and postal services) and about other costs, and when it is not possible to determine the amount of these fees – the obligation to pay them, the Customer is informed on the Online Store website when placing the Order, including when the Customer wishes to be bound by the Sales Agreement.
The procedure for concluding a Sales Agreement in the Online Store using the Order Form

Conclusion of a Sales Agreement between the Customer and the Seller takes place after the Customer has placed an Order in the Online Store in accordance with point 2.1.2 of the Regulations.

After placing the Order, the Seller immediately confirms its receipt and at the same time accepts the Order for execution. Confirmation of receipt of the Order and its acceptance for implementation occurs by sending the Customer an appropriate e-mail to the Customer’s e-mail address provided when placing the Order, which contains at least the Seller’s statement about the receipt of the Order and its acceptance for implementation and confirmation of the conclusion of the Sales Agreement. As soon as the Customer receives the above e-mail, a Sales Agreement is concluded between the Customer and the Seller.

Consolidation, protection and making available to the Customer the content of the concluded Sales Agreement is made by (1) providing these Regulations on the Online Store website and (2) sending the Customer the e-mail message referred to in point 3.3.2. Regulations. The content of the Sales Agreement is additionally recorded and secured in the IT system of the Seller’s Online Store.
METHODS AND DEADLINES FOR PAYMENT FOR THE PRODUCT
The Seller provides the Customer with the following payment methods under the Sales Agreement:

Payment in cash on delivery on delivery.

Payment in cash on personal pickup.

Payment by bank transfer to the Seller’s bank account.

Electronic payments and card payments via the Cashbill.pl website – current payment methods are available on the Online Store’s website in the information tab on payment methods and on the website http://www.cashbill.pl.

Settlements of electronic payments and payment cards are carried out in accordance with the Customer’s choice via the Cashbill.pl website. Electronic payments and payment cards are managed by:

Cashbill.pl – CashBill S.A. with its registered office in Katowice (address: ul. Sobieskiego 2, 40-082 Katowice), entered into the Register of Entrepreneurs of the National Court Register under number 0000323297, registration files kept by the District Court Katowice – Wschód in Katowice, VIII Commercial Department of the National Court Register, capital in the amount of PLN 5,000,000.00 fully paid, NIP: 6292410801, REGON: 241048572.

Bitcoin payments through Coinpayments.net (CoinPayments Inc. 808 Nelson St., Vancouver, British Columbia, V6Z 2H2, Canada, website address: https://www.coinpayments.net).

Payment deadline:

If the Customer chooses payment by bank transfer, electronic payment or payment by credit card, the Customer is obliged to make the payment within 14 calendar days from the date of the Sale Agreement.

If you choose
deadline, which, however, cannot exceed 2 Business Days. The beginning of the delivery period of the Product to the Customer counts as follows:

If the Customer chooses the method of payment by bank transfer, electronic payment or payment card – from the date of crediting the Seller’s bank account or settlement account.

If the Customer chooses the method of payment in cash on delivery – from the date of the Sale Agreement.

Product readiness for collection by the Customer – if the Customer chooses to collect the Product in person, the Product will be ready for collection by the Customer within 2 Business Days, unless a shorter period is given in the description of the Product or when placing the Order. In the case of Products with different terms of readiness for collection, the term of readiness for collection is the longest period provided, which, however, may not exceed 2 Business Days. The Customer will be additionally informed by the Seller about the readiness of the Product for collection. The beginning of the product’s readiness for collection by the Customer counts as follows:

If the Customer chooses the method of payment by bank transfer, electronic payment or payment card – from the date of crediting the Seller’s bank account or settlement account.

If the Customer chooses the method of cash on delivery – from the date of the Sale Agreement.

PRODUCT COMPLAINT
The basis and scope of the Seller’s liability to the Customer, if the Product sold has a physical or legal defect (warranty) are set out in generally applicable law, in particular in the Civil Code (including Articles 556-576 of the Civil Code).
The Seller is obliged to provide the Customer with a Product without defects. Detailed information on the Seller’s liability due to a Product defect and Customer’s rights are set out on the Online Store’s website in the complaint information tab.
The complaint may be submitted by the Customer, for example:

in writing to the address: Daniszewska 24C lok. 15, 03-230 Warsaw;

in electronic form via e-mail to the following address: kontakt@vichemic.pl.

It is recommended that the customer provide in the complaint description: (1) information and circumstances regarding the subject of the complaint, in particular the type and date of the defect; (2) demanding how to bring the Product into compliance with the Sales Agreement or a statement on price reduction or withdrawal from the Sales Agreement; and (3) contact details of the person submitting the complaint – this will facilitate and accelerate the consideration of the complaint by the Seller. The requirements given in the previous sentence are only recommendations and do not affect the effectiveness of complaints submitted without the recommended description of the complaint.
The Seller will respond to the Customer’s complaint immediately, no later than within 14 calendar days from the date of its submission. If the Customer who is a consumer demanded replacement of the item or removal of the defect or submitted a price reduction statement specifying the amount by which the price is to be reduced, and the Seller did not respond to this request within 14 calendar days, it is considered that the request was justified. .
The customer who exercises the warranty rights is obliged to deliver the defective product to the address: Daniszewska 24C lok. 15, 03-230 Warsaw. In the case of a Customer who is a consumer, the cost of delivery of the Product shall be borne by the Seller, in the case of a Customer who is not a consumer the cost of delivery shall be borne by the Customer. If, due to the type of Product or the way it was installed, delivery of the Product by the Customer would be excessively difficult, the Customer is obliged to make the Product available to the Seller at the place where the Product is located.
EXTRAJUDICIAL WAYS OF EXAMINING COMPLAINTS AND INVESTIGATING CLAIMS AND RULES OF ACCESS TO THESE PROCEDURES
Detailed information on
the possibility for a customer who is a consumer to use out-of-court complaint consideration and redress methods and the rules for accessing these procedures are available on the website of the Office of Competition and Consumer Protection at: https://uokik.gov.pl/pozasadowe_rozwiazywanie_sporow_konsumenckich.php.
There is also a contact point at the President of the Office for Competition and Consumer Protection (phone: 22 55 60 333, email: kontakt.adr@uokik.gov.pl or in writing: Plac Powstańców Warszawy 1, 00-030 Warsaw.), Whose task is among other things, providing assistance to consumers in matters relating to the out-of-court resolution of consumer disputes.
The consumer has the following examples of possibilities to use extrajudicial methods of dealing with complaints and redress: (1) a request to settle a dispute to a permanent amicable consumer court (for more information please visit: http://www.spsk.wiih.org.pl/); (2) a request for out-of-court resolution of the dispute to the voivodeship inspector of the Trade Inspection (more information on the website of the inspector competent for the place of business of the Seller); and (3) assistance of the poviat (municipal) consumer ombudsman or social organization, whose statutory tasks include consumer protection (among others, the Consumer Federation, the Association of Polish Consumers). Advice is provided, among others, by e-mail atady@dlakonsumentow.pl and at the consumer helpline number 801 440 220 (helpline open on Business Days between 8:00 and 18:00, connection fee according to the operator’s tariff).
At http://ec.europa.eu/consumers/odr there is a platform available for online dispute resolution between consumers and businesses at EU level (ODR platform). The ODR platform is an interactive and multilingual website with a one-stop shop for consumers and entrepreneurs seeking out-of-court settlement of a dispute regarding contractual obligations arising from an online sales contract or service contract (more information on the platform’s website or at the Office of Competition and Consumer Protection’s website : https://uokik.gov.pl/spory_konsumenckie_faq_platforma_odr.php).
RIGHT TO WITHDRAW FROM THE CONTRACT
A consumer who has entered into a distance contract may, within 14 calendar days, withdraw from it without giving a reason and without incurring costs, except for the costs specified in point 8.8 of the Regulations. To meet the deadline, it is enough to send a statement before its expiry. A declaration of withdrawal may be made, for example:

in writing to the address: Daniszewska 24C lok. 15, 03-230 Warsaw;

in electronic form via e-mail to the following address: kontakt@vichemic.pl.

An exemplary model withdrawal form is included in Annex 2 to the Consumer Rights Act and is additionally available in section 11 of the Regulations and on the Online Store website in the tab regarding withdrawal from the contract. The consumer can
use the form template, but it is not mandatory.
The deadline to withdraw from the contract begins:

for the contract under which the Seller issues the Product, being obliged to transfer its ownership (e.g. Sales Contract) – from taking possession of the Product by the consumer or a third party indicated by him other than the carrier, and in the case of a contract which: (1) includes many Products that are delivered separately, in batches or in parts – from taking possession of the last Product, batch or part, or (2) consist in regular delivery of Products for a specified period – from taking possession of the first of the Products;

for other contracts – from the date of the contract.

In the event of withdrawal from a distance contract, the contract is considered void.
The Seller is obliged to immediately, not later than within 14 calendar days from the date of receipt of the consumer’s statement of withdrawal from the contract, return to the consumer all payments made by him, including the costs of delivery of the Product (with the exception of additional costs arising from the method of delivery chosen by the consumer other than the cheapest regular delivery method available in the Online Store). The seller reimburses the payment using the same method of payment as used by the consumer, unless the consumer has expressly agreed to a different method of reimbursement that does not involve any costs for him. If the Seller has not offered to collect the Product from the consumer himself, he may withhold the reimbursement of payments received from the consumer until he receives the Product back or the consumer provides proof of his return, depending on which event occurs first.
The consumer is obliged to immediately, not later than within 14 calendar days from the day on which he withdrew from the contract, return the Product to the Seller or hand it over to a person authorized by the Seller to collect, unless the Seller has offered to collect the Product himself. To meet the deadline, it is sufficient to return the Product before its expiry. The consumer may return the Product to the address: Daniszewska 24C lok. 15, 03-230 Warsaw.
The consumer is responsible for reducing the value of the Product as a result of using it in a way that goes beyond what is necessary to establish the nature, characteristics and functioning of the Product.
Possible costs related to the consumer’s withdrawal from the contract, which the consumer is obliged to bear:

If the consumer has chosen a method of delivery of the Product other than the cheapest regular delivery method available in the Online Store, the Seller is not obliged to refund the additional costs incurred by the consumer.

The consumer bears the direct cost of returning the Product.

In the case of a Product which is a service, the performance of which – at the express request of the consumer – began before the deadline to withdraw from the contract, the consumer who exercises the right to withdraw from the contract after making such a request, is required to pay for the services fulfilled until the withdrawal from the contract. The amount of payment is calculated in proportion to the scope of the service rendered, taking into account the price or remuneration agreed in the contract. If the price or remuneration is excessive, the basis for calculating this amount is the market value of the service provided.

The right to withdraw from a distance contract is not entitled to the consumer in respect of contracts:

(1) for the provision of services, if the Seller has fully performed the service with the express consent of the consumer, who was informed before the start of the service that after the performance of the service by the Seller he will lose the right to withdraw from the contract; (2) in which the price or remuneration depends on fluctuations in the financial market over which the Seller has no control, and which may occur before the deadline to withdraw from the contract; (3) in which the subject of the service is a non-prefabricated product, manufactured according to the specifications of the consumer or serving to satisfy his individual needs; (4) in which the subject of the service is a Product that deteriorates quickly or has a short shelf life; (5) in which the subject
benefits is a Product delivered in a sealed package, which cannot be returned after opening due to health protection or hygiene reasons, if the packaging was opened after delivery; (6) in which the subject of the service are Products that after delivery, due to their nature, are inseparably connected with other things; (7) in which the subject of the service are alcoholic beverages, the price of which was agreed at the conclusion of the Sales Agreement, and whose delivery may take place only after 30 days and whose value depends on fluctuations in the market over which the Seller has no control; (8) in which the consumer expressly demanded that the Seller visit him for urgent repair or maintenance; if the Seller provides additional services other than those requested by the consumer, or provides Products other than spare parts necessary for the performance of repair or maintenance, the consumer has the right to withdraw from the contract in respect of additional services or Products; (9) in which the subject of the service are sound or visual recordings or computer programs delivered in a sealed package, if the package was opened after delivery; (10) for delivering newspapers, periodicals or magazines, with the exception of subscription contracts; (11) concluded through a public auction; (12) for the provision of accommodation services other than for residential purposes, the carriage of goods, car rental, gastronomy, leisure services, entertainment, sports or cultural events, if the contract indicates the day or period of service provision; (13) for the supply of digital content that is not saved on a tangible medium, if the performance of the service began with the express consent of the consumer before the deadline to withdraw from the contract and after informing him by the Seller about the loss of the right to withdraw from the contract.

PROVISIONS CONCERNING ENTREPRENEURS
This section of the Regulations and the provisions contained herein apply only to Customers and Service Users who are not consumers.
The Seller has the right to withdraw from the Sales Agreement concluded with a Customer who is not a consumer within 14 calendar days from the date of its conclusion. Withdrawal from the Sales Agreement in this case may occur without giving a reason and does not give rise to any claims on the part of the Customer who is not a consumer against the Seller.
In the case of Customers who are not consumers, the Seller has the right to limit the available payment methods, including requiring prepayment in whole or in part, regardless of the payment method chosen by the Customer and the fact of concluding the Sales Agreement.
When the Seller releases the Product to the carrier, the non-consumer Customer receives the benefits and burdens associated with the Product and the risk of accidental loss or damage to the Product. In this case, the Seller shall not be liable for any loss, defect or damage of the Product arising from its acceptance for transport until its delivery to the Customer and for delay in the shipment’s delivery.
If the Product is sent to the Customer via a carrier, the Customer who is not a consumer is obliged to examine the parcel in time and in the manner adopted for such shipments. If it finds that during transport there was a loss or damage to the Product, it is obliged to perform all actions necessary to determine the liability of the carrier.
In accordance with art. 558 § 1 of the Civil Code, the Seller’s liability under the warranty for the Product towards the Customer who is not a consumer is excluded.
In the case of Service Recipients who are not consumers, the Service Provider may terminate the contract for the provision of Electronic Services with immediate effect and without indicating the reasons by sending the Customer a relevant statement.
Liability of the Service Provider / Seller in relation to the Service Recipient / Non-Customer
the consumer, regardless of its legal basis, is limited – both as part of a single claim, as well as for all claims in total – to the amount of the price paid and delivery costs under the Sales Agreement, but not more than to the amount of one thousand zlotys. The Service Provider / Seller shall be liable to the Service Recipient / Customer who is not a consumer only for typical damages foreseeable at the time of conclusion of the contract and shall not be liable for lost profits in relation to the Service Recipient / Customer who is not a consumer.
All disputes arising between the Seller / Service Provider and the Customer / Service Recipient who is not a consumer shall be submitted to the court having jurisdiction over the seat of the Seller / Service Provider.
FINAL PROVISIONS
Agreements concluded through the Online Store are concluded in Polish.
Change of Regulations:

The Service Provider reserves the right to amend the Regulations for important reasons, i.e. changes to the law; changes in payment and delivery methods – to the extent that these changes affect the implementation of the provisions of these Regulations.

In the event of permanent contracts being concluded pursuant to these Regulations (e.g. provision of Electronic Services – Account), the amended Regulations shall bind the Service Recipient, if the requirements specified in art. 384 and 384 [1] of the Civil Code, i.e. the Customer has been properly notified of the changes and has not terminated the contract within 14 calendar days of the date of notification. In the event that a change in the Regulations results in the introduction of any new fees or increase in existing fees, the Customer who is a consumer has the right to withdraw from the contract.

In the case of conclusion of contracts other than continuous contracts pursuant to these Regulations (e.g. Sales Agreement), amendments to the Regulations will not in any way affect the acquired rights of Service Recipients / Customers who are consumers before the date of entry into force of amendments to the Regulations, in particular changes to the Regulations will not impact on already placed or submitted Orders and concluded, implemented or executed Sales Agreements.

In matters not covered by these Regulations, generally applicable provisions of Polish law shall apply, in particular: the Civil Code; the Act on the provision of electronic services of July 18, 2002 (Journal of Laws 2002 No. 144, item 1204, as amended); for Sales Agreements concluded until December 24, 2014 with customers who are consumers – the provisions of the Act on the protection of consumer rights and liability for damage caused by a dangerous product of March 2, 2000 (Journal of Laws 2000 No. 22, item 271 from as amended) and the Act on specific conditions of consumer sales and amendment to the Civil Code of 27 July 2002 (Journal of Laws 2002 No. 141, item 1176, as amended); for Sales Agreements concluded from December 25, 2014 with customers who are consumers – provisions of the Act on Consumer Rights; and other relevant provisions of applicable law.
MODEL WITHDRAWAL FROM THE CONTRACT
(ANNEX NUMBER 2 TO THE CONSUMER RIGHTS ACT)

Model withdrawal form
(this form should be completed and returned only if you wish to withdraw from the contract)

– Addressee:

Vichemic Industries Norbert Szmajdewicz
Daniszewska 24C lok. 15, 03-230 Warsaw
vichemic.pl
kontakt@vichemic.pl

– I / We (*) hereby inform / inform (*) about my / our withdrawal from the contract of sale of the following items (*) contract of delivery of the following items (*) contract for a specific work involving the performance of the following items (*) / for the provision of the following service (*)

– Date of conclusion of the contract (*) / receipt (*)

– Name of consumer (s)

– Address of consumer (s)

– Signature of the consumer (s) (only if the form is sent on paper)

– Date

(*) Delete as applicable.