Revocation form

Recipient:

SelfDelve
Anja Koschemann
Berliner Str. 19
D - 01067 Dresden

Phone: +49 351 3177630
Fax: +49 351 3177639
eMail: info@selfdelve.com

Order Number or Invoice Number *

Order Date or Shipping Date *

Last Name, First Name *

Email Address *

Please Select *

I would like to choose another toy

Please refund me the purchase price by bank transfer

Please refund me the purchase price via PayPal

Account Owner

IBAN *

BIC

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