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Return Form

To :

black palms

S. Ebert & M. Ebert & Sammer GbR

Bgm.-Deffner-Straße 4

D-85586 Poing

GERMANY

E-Mail shop@black-palms-shop.com.

I want to refund the concluded contract for the purchase of the following products

_____________________________________________________

Ordered on /received on

__________________

Ordernumber

__________________

Customer Name

_____________________________________________________

Customer Address
_____________________________________________________

Paid with PayPal: PayPal Mail address
_____________________________________________________

Paid with Bank transfer

Account owner___________________________________________
IBAN:_________________________________________________
SWIFT BIC:_____________________________________________

Customer signature

__________________

Date

__________________

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