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TERMS & CONDITIONS
FOR THE ONLINE SHOP EISKU.COM

Definitions

The terms used in these Terms and Conditions shall have the following meaning:

 

a) Business Days – these shall be the days from Monday to Friday, excluding public holidays.

b) Customer – a natural person with full legal capacity, and in the cases provided for by generally applicable laws also a natural person with limited legal capacity; a legal person or an organizational unit without legal personality, to which the law grants legal capacity; - who places an order or uses other Services available in the Online Shop under the provisions of these Terms and Conditions.

c) Account – a section of the Online Shop ascribed to the Customer that he can use to perform specific actions in the Online Shop.

d) Consumer – a natural person performing a legal transaction with an entrepreneur not directly related to its business or professional activity.

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

f) Consumer Rights Act - the Act of 30 May 2014 on consumer rights.

g)Newsletter service- the Seller’s commercial information in the form of messages sent to the Customer’s electronic mail address.

h) Personal Data – shall mean personal data within the meaning of Article 4(1) of the Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of individuals with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC (General Data Protection Regulation).

i) Product – a movable item available in the Online Shop that is the subject of the Sale Agreement between the Customer and the Seller being paid by the Price.

j) Sales Agreement – a sales agreement of Products concluded between the Seller and the Customer.

k) Seller - the company EISKU Piotr Łukasiuk, Wiejska 13, 82-100 Nowy Dwór Gdański, Poland, Vat number: PL5792284003, e-mail:   eisku@eisku.com .

l) Services – the services rendered electronically by the Seller for the benefit of Customers.

m) Terms and Conditions – this document.

General
Provisions

  1. These Terms and Conditions specify the general conditions and ways of provision of services electronically and selling via the Online Shop https://www.eisku.com/ .

  2. These Terms and Conditions are always available at the website https://www.eisku.com/  which allows to download, display and record their contents by printing or saving them to a data carrier at any time.

  3. The Online Shop can only be used by those who have read and fully accepted this terms and condition for the online shop.  The Online Shop can only be used by those who have read and fully accepted this terms and condition for the online shop. 

  4. The Online Shop may be accessed if the IT equipment used by the Customer meets the following minimum technical requirements: a computer or a mobile device with access to the Internet, access to electronic mail, a browser Firefox, Chrome, Safari, Internet Explorer, Edge, Opera, enabling cookies and JavaScript in the web browser.

  5. The Seller informs that the public nature of the Internet and the use of services provided electronically may be associated with the risk of obtaining and modifying Customers data by unauthorized persons, therefore Customers should use appropriate technical measures that will minimize the above-mentioned threats, e.g.  Antivirus.

  6. The Customer is obliged to:​

a) provide in the Order and in the registration forms, only true, up-to-date and all  necessary data of the Customer and promptly update the data;

b) use the services made available by the Seller in a way that it does not interfere with the functioning of the Seller, the Online Shop and other Customer;

c) use the services made available by the Seller in a manner consistent with the applicable laws, and provisions of the Terms and Conditions.

Electronic services in the online shop

  1. The Services are rendered by the Seller free of charge, 24 hours a day, 7 days a week.

  2. The Seller provides the following Electronic Services:

a) Account ;

b) Newsletter ;

c) Enabling Customers to place orders and conclude Sale Agreements under the terms specified in these Terms;

  3. Using the Account is possible after completing jointly and severally the following                      steps by the Customer:

- Completing the registration form and accepting the provisions of these Terms,

- Clicking on the "Register" box.

  4. Following the registration of the Customer Account, a customer can log in to the                         Online Shop, indicating the email address and password provided at the registration.

  5. The Agreement for the provision of service which involves maintenance of an Account            in the Online Shop shall be concluded for an indefinite period and shall be terminated              when the Customer submits a request to remove the account or uses the button                         “Delete Account”.

  6. The Newsletter service, provided at the request of the Customer after the conclusion                of the Agreement, includes receiving by the Customers who have provided the                          Service Provider with their e-mail address, by electronic means commercial                                information regarding the products and services of the Service Provider, including in                particular information about their current offer, promotions, discounts and marketing             campaigns,

  7. The Agreement for the provision of the Newsletter service shall be concluded for an                  indefinite period and shall be terminated when the Customer submits a request to                      remove his electronic mail address from the Newsletter subscription list or when he                  unsubscribes by the link included in the message sent as part of the Newsletter                           service.

 8. The Agreement for the provision of service which involves enabling Customers to place           orders in the Online Shop shall be concluded for a definite period and shall be                             terminated when the Order is placed through it or when the Customer earlier                               terminates placing the Order through it.

  9. The Seller may at any time terminate the Service Agreement with the Customer giving            a 14 day notice period for important reasons, understood as a change in the laws                      governing the provision of electronic services by the Seller affecting the mutual rights              and obligations set out in the agreement concluded between the Customer and the                  Seller, or a change of the scope or provision of services to which the provisions of the              Terms and Conditions apply.

  10. If the Customer breaches these Terms and Conditions, the Seller – after a prior                           ineffective cease and desist letter setting an appropriate deadline – may terminate                   the agreement for the provision of Services upon a 14- day notice.

  11. Either party withdrawing from the Service Agreement, or the Agreement being                         terminated by mutual consent, does not have an impact on the rights acquired by the               parties before withdrawing from or terminating the agreement.

Orders / Sales Agreement

  1. Information about the Products as provided on the Shop websites, in particular their descriptions, technical and functional parameters as well as prices constitute an invitation to conclusion of an Agreement within the meaning of Article 71 of the Civil Code.

  2. All the Products available in the Online Shop are free of physical and legal defects.

  3. The Seller enables the Customer to place an Order through the Online Shop, 24/7.

  4. Orders can be placed by Internet users, who have correctly filled in registration form. Orders can be placed also without registration form. A user who does not have an Account must independently fill out the Order Form in the scope of his/her details necessary to conclude and execute the Sales Agreement.

  5. As part of placing an order, the Customer provides his/her personal data marked in the order form as obligatory. Providing the personal data marked obligatory is voluntary yet is necessary for placing the order. Providing the personal data not marked as obligatory is voluntary and unnecessary for placing the order. A lack of due diligence while filling in the form may cause the Customer being obligated to cover additional expenses such as: compensation, costs of improper postage, costs of resending the order to the right address, or any other rightful costs incurred by the Online Shop to complete the Order.

  6. The order form should include the Customer’s name, surname and postal address, phone number and email address.

  7. The Customer sends the Order by means of the Online Shop functionality provided for that purpose with an obligation to pay. If the Customer does not have an Account, it is required to accept the Terms and Conditions.

  8. If the Order is placed via the Order form available on the Online Shop website, the Customer places the Order with the Seller electronically, which constitutes an offer to conclude an Agreement for the Sales of the Products being the subject of the Order. The offer made electronically shall be binding for the Customer if the Seller sends – to the electronic mail address provided by the Customer – a confirmation of acceptance of the Order for processing, in the form of the Seller’s declaration of acceptance of the Customer’s offer; upon its receipt by the Customer the Sales Agreement shall be concluded.

  9. The total value of the Order includes the price and shipping costs.

  10. The sales Agreement shall be concluded in English.

Delivery 

  1. Delivery of the Products is performed to the address indicated by the Customer when placing the Order (EU)

  2. Delivery of the Products is carried out by parcel delivery company.

  3. On the Shop websites, in the description of the Products, the Seller informs the Customer about the number of Business Days needed to process the Order and to deliver it, as well as about the delivery charges. Details in section Delivery.

  4. The deadline for delivery and processing of the Order shall be calculated per Business Days.

  5. If the ordered Products have different delivery deadlines, the longest deadline shall apply to the whole Order.

Prices and methods of payment

  1. The prices are provided in EUR. The prices include VAT (Value added Taxes) with delivery in EU countries.

  2. The Customer may choose the following payment methods:

a) credit or debit card (Visa, Mastercard).

b) electronic payment .

  3. Online payments are processed by:

-Stripe Payments Europe, Ltd, 1 Grand Canal Street Lower, Grand Canal Dock, Dublin

- PayPal, (PayPal (Europe) S.à r.l. & Cie, S.C.A., 5. Etage, 22-24 Boulevard Royal, 2449 Luxembourg.

 4.  When making a payment, the Customer will be informed immediately before making           the payment about the amount in which the payment should be made, about the                     possible methods of its execution and about the data of the payment provider, if the             given service is possible. Detailed terms and conditions for making payments through           the operators performing electronic payments are available on the website of the                   given operator.

  5. When making a payment via an electronic payment operator, the User should follow            the instructions given by the operator of electronic payments in order to make a                      payment.

  6. The customer agrees that the purchase documents (VAT invoice / receipt) for the                      order will be sent electronically.

The right to withdraw from the agreement

  1. The consumer who has concluded a distance agreement can withdraw from sales agreement within 14 calendar days without giving a reason and without incurring costs, except for the costs specified in VII.12 and VII.16 of these Regulations. To keep the deadline, it is sufficient for the Consumer to make a statement of the Seller before it expires.

  2. The statement of withdrawal from the agreement may be submitted to the Seller's address or e-mail address: eisku@eisku.com .The Customer may compose the declaration by himself or use the form of declaration of withdrawal from Agreement (Appendix No 1). 

  3. The course of time for withdrawal from the Sales Agreement shall commence a) on the date on which the Product was taken by the Consumer or by a third party designated by him/her other than the carrier and in the case of a Sale Agreement, which:(1)includes a great number of Products that are delivered separately, in batches or in parts, since acquiring possession of the last Product, a batch or part, or (2) is based on regular delivering Products for a fixed period of time – since acquiring possession of the first of the Products; b) for other agreements – from the date of conclusion of the contract.

  4. Upon receipt of the statement of withdrawal from the Agreement by the Consumer, the Seller will send to the Consumer's e-mail address a confirmation of receipt of the statement of withdrawal from the Agreement.

  5. In the case of withdrawal from a distance Agreement, such an Agreement shall be deemed not concluded.

  6. The Seller is obliged immediately, but not later than within 14 calendar days from the date of receipt of the consumer's statement of withdrawal from the agreement, to return to the consumer all payments made by him, including the costs of delivery of the Product – movable item, including movable item with digital elements.   The Seller shall refund the payment with the same method of payment as was used by the Consumer, unless the Consumer agrees to another way of refund, whereas such a refund shall not generate any cost for the Consumer.

  7. The provisions of paragraph 6 do not apply to additional costs resulting from the method of delivery of products chosen by the consumer other than the cheapest usual delivery method available in the Online Store.

  8. In regard to Products – movable items (including movable items with digital elements), the Consumer is obliged to immediately, no later than within 14 calendar days from the date on which he withdrew from the agreement, return the Product to the Seller or hand it over to a person authorized by the Seller to collect it, unless the Seller offered to collect the Product himself. To meet the deadline, it is sufficient to send the Product back before its expiry.

  9. The purchased Products should be returned to the following address: EISKU Piotr Łukasiuk, ul. Wiejska 13, 82-100 Nowy Dwór Gdański (Poland).

  10. The Consumer is responsible for reducing the value of the Product – a movable item (including movable item with digital elements) – 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.

  11. With regard to Products – movable items (including movable items with digital elements), the Seller may withhold the refund of payments received from the consumer until the Product is received back or the consumer provides proof of its return, whichever occurs first, unless the Seller himself offered to collect the Product from the consumer.

  12. With regard to Products – movable items (including movable items with digital elements) – the consumer bears the direct costs of returning the Product.  If the consumer has chosen a method of delivery of the Product other than the cheapest usual delivery method available in the Online Store, the Seller is not obliged to refund the additional costs incurred by the consumer.

  13. In the event of withdrawal from the contract for the delivery of the Product – digital content or digital service – the Seller from the date of receipt of the consumer's statement of withdrawal from the agreement may not use content other than personal data provided or created by the consumer during the use of the Product – digital content or digital service – provided by the Seller, except for content that:

1) is only useful in relation to the digital content or digital service which was the subject of the contract;

2) relate exclusively to the consumer's activity when using the digital content or digital service which was the subject of the contract;

3) have been combined by the trader with other data and cannot be disconnected without undue difficulty;

4) they have been made jointly by the consumer with other consumers who can still benefit from them.

  14. Except for the cases referred to above in paragraph 13 points (1 -3), the Seller, at the             consumer's request, provides him with content other than personal data that has                     been provided or created by the consumer in the course of using digital content or a             digital service provided by the Seller. In the event of withdrawal from the contract,                 the Seller may prevent the consumer from further use of the digital content or digital               service, in particular by preventing the consumer from accessing the digital content               or digital service or blocking the user's account, which does not affect the consumer's             rights referred to in the previous sentence. The consumer has the right to retrieve the             digital content from the Seller free of charge, without hindrance from the Seller,                       within a reasonable time and in a commonly used machine-readable format.

  15. In the event of withdrawal from the contract for the supply of the Product – digital                   content or digital service, the consumer is obliged to stop using this digital content or             digital service and making it available to third parties.

  16. With regard to Product – 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 submitting such           a request is obliged to pay for the services provided until the withdrawal from the                   contract. The amount of payment is calculated in proportion to the scope of the                       service provided, considering the price or remuneration agreed in the contract. If the           price or remuneration is excessive, the basis for calculating this amount shall be the               market value of the service provided.

  17. The right to withdraw from a distance agreement is not entitled to the Consumer in                 relation to contracts:

a) for the provision of services for which the consumer is obliged to pay the price, if the Seller has fully performed the service with the express and prior 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, and took note of it;

b) 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;

c) in which the subject of the service is a Product – movable item (including movable item with digital elements) – non-prefabricated, manufactured according to the consumer's specifications or serving to satisfy his individual needs;

d) in which the subject of the service is a Product – a movable item (including a movable item with digital elements) – subject to rapid deterioration or having a short shelf life;

e) in which the subject of the service is a Product – a movable item (including a movable item with digital elements) – delivered in a sealed package, which after opening the packaging cannot be returned due to health protection or hygiene reasons, if the packaging was opened after delivery;

f) in which the subject of the service are Products – movable items (including movable items with digital elements) – which, after delivery, due to their nature, are inseparably connected with other movable items, including movable items with digital elements;

g) 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;

h) in which the consumer expressly demanded that the Seller come to him for urgent repair or maintenance; if the Seller provides additional services other than those requested by the consumer, or provides Products – movable items (including movable items with digital elements), other than spare parts necessary to perform repair or maintenance, the right to withdraw from the contract is entitled to the consumer in relation to additional services or Products;

i) in which the subject of the service are sound or visual recordings or computer programs delivered in a sealed package, if the packaging has been opened after delivery;

j) for the supply of newspapers, periodicals or magazines, with the exception of subscription contracts;

k) concluded by way of a public auction;

l) for the provision of services in the field of accommodation, other than for residential purposes, carriage of goods, car rental, catering, services related to leisure, entertainment, sports or cultural events, if the contract specifies the day or period of the service;

m) for the delivery of digital content not supplied on a tangible medium, for which the consumer is obliged to pay the price, if the Seller began the service with the express and prior 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, and took note of it, and the Seller provided the consumer with the confirmation referred to in Article 15 paragraph 1 and 2 or Article 21 paragraph 1 of the Consumer Rights Act;

n) for the provision of services for which the consumer is obliged to pay the price for which the consumer has expressly requested the Seller to come to him for repair, and the service has already been fully performed with the express and prior consent of the consumer.

  18. The provisions concerning the consumer shall apply to sole traders who conducts                     business activity concluding a contract directly related to their business activity,                       where it is apparent from such agreements that they do not have professional                           character for them.  To determine whether a sole trader has, in particular                                   circumstances, consumer rights, it is necessary to verify the professional nature of the           agreement, especially on the basis of information recorded in the Central                                   Registration and Information on Business (CEIDG-in Poland).

Complaints

  1. This section of the Terms and Conditions defines the complaint handling procedure for all complaints submitted to the Seller.

  2. In the event of non-compliance of the Product with the sales agreements, the provisions of Book Three of Title XI, Section II of the Civil Code Act do not apply to consumers, only the provisions set out in the Consumer Rights Act (Chapter 5A).

  3. Complaints should be sent to the following address: EISKU Piotr Łukasiuk, ul. Wiejska 13, 82-100 Nowy Dwór Gdański(Poland), e-mail: eisku@eisku.com .

  4. The Seller undertakes to process each complaint immediately, no later than within 14 calendar days from the date of its receipt.

  5. If the product is not in conformity with the contract, the consumer may request its repair or replacement. The Seller shall carry out repair or replacement within a reasonable time after being informed by the consumer of the lack of conformity and without undue inconvenience to the consumer considering the specificity of the product and the purpose for which the consumer acquired it. The costs of repair or replacement, including in particular the costs of postage, transport, labor and materials, shall be borne by the Seller.

  6. The Consumer makes available to the Seller a product subject to repair or replacement. The Seller collects the products from the consumer at his own expense. The Consumer is not obliged to pay for the normal use of the products which have subsequently been replaced.

  7. If the product is not in conformity with the contract, the consumer may make a statement on price reduction or withdrawal from the contract when:

a) the seller refused to bring the product into conformity with the contract in accordance with the Consumer Rights Act.​

b) the seller has not brought the product into conformity with the contract in accordance with the Consumer Rights Act.

c) the lack of conformity of the product with the contract persists even though the seller has tried to bring the product into conformity.

d) the lack of conformity of the product with the contract is so significant that it justifies a price reduction or withdrawal from the contract without prior use of protection measures specified in the Consumer Rights Act.

e) It is clear from the seller's declaration or circumstances that he will not bring the products into conformity within a reasonable time or without undue inconvenience to the consumer.

  8. The reduced price must be in proportion to the contract price in which the value of the            non-conforming product remains in relation to the value of the product in conformity.

  9. The Seller shall return to the consumer the amounts due as a result of exercising the                right to reduce the price immediately, no later than within 14 days from the date of                  receipt of the consumer's statement on the price reduction.

 10. In the event of withdrawal from the contract, the Consumer immediately returns the              products to the Seller at his expense. The Seller returns the price to the consumer                    immediately, no later than within 14 days from the date of receipt of the product or                  proof of its return.

 11.  The Consumer may not withdraw from the contract if the lack of conformity of the                    product with the contract is irrelevant. The lack of conformity of a product with the                  contract shall be presumed to be material.

 12. It is recommended that the Customer provides the following in the complaint                             description: (1) information and circumstances regarding the subject of the complaint,           in particular circumstances indicating the non-compliance of the Product with the                   Sales Agreement; (2) request repairs or replacement, or statement of price reduction,         or withdrawal from the Sales Agreement in the cases indicated in the Consumer Rights         Act and (3) the claimant’s contact information. The requirements given in the previous           sentence are only a recommendation and do not affect the effectiveness of complaints         submitted without the recommendation.

13. The complaint may be accompanied by evidence (e.g. photos, documents or the                     Product) related to the subject of the complaint.

14. The Seller is liable for non-compliance of the Product with the Sales Agreement if the             non-compliance of the Product with the Sales Agreement existed at the time of its                   delivery and was revealed within two years from the date of delivery of the Product to         the Consumer.

15. The Consumer may use the guarantee if it was granted by the Seller.

16. The provisions concerning the consumer shall apply to sole traders who conducts                    business activity concluding a contract directly related to their business activity, where          it is apparent from such agreements that they do not have professional character for            them.  To determine whether a sole trader has, in particular circumstances, consumer          rights, it is necessary to verify the professional nature of the agreement, especially on            the basis of information recorded in the Central Registration and Information on                      Business (CEIDG-in Poland).

 17. The Seller complies with the provisions of Chapter 5B of the Consumer Rights Act in the          scope of contracts for the supply of digital content or digital service. The Seller shall              be liable for any lack of conformity with the contract of the digital content or digital                service supplied on a continuous basis which occurred or became apparent at the                  time when the contract was intended to supply it. That period shall not be less than                two years from the time of delivery of the products with digital elements. The lack of              conformity of the digital content or digital service shall be presumed to have occurred          at that time if it became apparent at that time.

Out-of-court complaint handling and redress procedures

  1. The Seller would like to inform you that out-of-court complaint handling and redress procedures can be used. They can be used on a voluntary basis and only if both parties to the dispute agree to it.

  2. Detailed information on consumer dispute resolution, including the possibility for the Consumer to use out-of-court complaint handling, redress and the rules of access to these procedures is available at the offices and on the websites of county (municipal) consumer advocates, Voivodship Inspectorates of Trade Inspection, in particular also at the following Internet address of the Office of Competition and Consumer Protection:

  3. https://www.uokik.gov.pl/pozasadowe_rozwiazywanie_sporow_konsumenckich.php

  4. https://www.uokik.gov.pl/pozasadowe_rozwiazywanie_sporow_konsumenckich.php

  5. For example, The Customer who is a Consumer has the right to refer to a permanent amicable consumer court operating by the Commercial Inspection with a request to settle a dispute arising out of the concluded Sales Agreement;

  6. According to article 14, paragraph. 1-2 of Regulation of the European Parliament and of the Council (EU) No 524/2013 from 21 May 2013, we commit ourselves to placing information on the ODR platform. Online Dispute Resolution is intended to facilitate an independent, non-judicial settlement of disputes between consumers and traders through the Internet. These disputes relate to contractual obligations arising from online sales or service contracts concluded between consumers living in the Union and traders established in the Union.

  7. The Consumer who would like to take advantage of the possibility of an amicable resolution to disputes concerning online purchases may submit a complaint, for example, via the EU"s Internet ODR platform which is available at: http://ec.europa.eu/consumers/odr/.

Force majeure

  1. Neither Party can be held liable for the non-performance of any of its obligations, if such non-performance is due to an unforeseeable event beyond its control or a force majeure incident including but not limited to epidemic, flood, fire, storm, raw materials shortage, transportation strike, partial or total strike, or lock-out. The Party affected by such events must inform the other party promptly, no later than five (5) business days after said event occurs.

  2. The parties agree that they will work together to determine how best to fill the order while the force majeure incident persists.

Protection of personal information

  1. The Seller collects and processes the personal information of the Customers in accordance with applicable provisions of law and with the Privacy Policy.

  2. The Seller applies appropriate technical and organizational measures to ensure the protection of personal data being processed.

  3. Additional explanations regarding the protection of personal data are contained in the “Privacy Policy”.

Final Provisions

  1. All and any rights of the Online Shop, including economic copyrights, intellectual property rights to its name, internet domain, the Online Shop website, and also to forms, logotypes are the property of the Seller and may be used solely in the manner indicated in and consistent with the Terms and Conditions.

  2. These Terms and Conditions will be governed by the law of the Republic of Poland. The parties expressly exclude the application of the UN Convention on Contracts for the International Sale of Goods.

  3. The choice of law made by the parties shall not have the result of depriving the consumer of the protection guaranteed to him by the mandatory rules of the law of the country in which he has his habitual residence in EU.

  4. In matters not regulated in these Terms and Conditions, the provisions of  Polish and EU law shall apply.

  5. Each Customer shall be informed about any changes to these Terms and Conditions by information available at the homepage of the Online Shop presenting a list of amendments and their effective dates. The Customers who possess an Account shall be additionally informed about the changes and presented with their list by a message sent to their electronic mail address. The effective date for any amendment shall fall at least 14 days after its publication. If the Customer who has a Customer Account does not accept the amended Terms and Conditions, he shall be obliged to notify this fact to the Seller within 14 days from being informed about the amendment of the Terms and Conditions. Notification of non-acceptance of the new Terms and Conditions shall result in termination of the Agreement.

Appendix No 1

Form of withdrawal from agreement

(this form should be filled in and returned only if you wish to withdraw from the contract)

 

- Address:

……………………

……………………

 

 - I / We (*) hereby inform / inform (*) of my / our withdrawal from the contract of sale of the following products

……………………………………………………………………………………..

 

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

 

- Name and surname of consumer (s)

 

- Consumer (s) address

 

- Signature of the consumer (s) (only if the form is sent in paper version)

 

- Date

 

(*) Delete as applicable.

.

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