WITHDRAWAL FORM

Please fill in the following information in the "Message" box below:

For the attention of L'Antidote, 7 passage du mûrier, 13520 Maussane-les-Alpilles

I hereby notify you of my withdrawal from the contract for the sale of a product from your collection as indicated below:

Ordered on: .....

Received on: ....

Order number: ....

Consumer Name: .....

Consumer address: .....

Consumer Signature .....

Date : .....