Revocation form

To:

portatronics Jan Fuerstenberg

Dorotheenstr. 34
53111 Bonn
Deutschland
Telefon:: +49228631627
Telefax:: +4922896399265
http://www.portatronics.de
E-mail:: support@portatronix.de
Unsere Umsatzsteuer ID: DE259171620

iThe present form will be sent to the e-mail-address of the on the left listed shop owner.
The mail will also be sent to your below indicated e-mail-address for your record.

If you have got a customer account with us, please log in - if you haven't done so already - and your customer data will be filled in automatically.

My customer data:

Customer No.:

Company name:

Name: *

Street + housenumber.: *

Postal code: *

City: *

Telephone no.: *

E-mail-address: *

Herewith I/we revoke the with you closed contract
about the purchase of the following goods / the provision of the following services:

Order or invoice no.: *
Please indicate the order or invoice no. for the items you will list below

Merchandise ordered the: *

Merchandise received the:

Item or model no.: *
Please indicate the model no. of the item you want to return for the above order or invoice no..
You will find the model no. on the respective invoice.

+ more items

– less items

+ more order numbers

– less order numbers

I wish the following proceeding: *
You may choose between voucher and your payment method. You can't choose a refunding method wich doesn't coincide with the payment method you payed your order with.

Account data:

Owner of account: *

Name of bank:

Account no.:

Bank code:

IBAN: *
(Indication necessary for bank transfers within SEPA range)

BIC: *
(Indication necessary for bank transfers within SEPA range)

Your individual message

Security code: