Complete and return this form only if you wish to cancel the contract:

— To MSA Investment GmbH, Ringstrasse 9-11, 50996, Köln, Germany, [[email protected]]:

— I/We [*] hereby give notice that I/We [*] cancel my/our [*] contract of sale of the following goods [*]/ for the supply of the following service [*],

— Ordered on [*]/received on [*],

— Name of consumer(s),

— Address of consumer(s),

— Signature of consumer(s) (only if this form is notified on paper),

— Date [*] Delete as appropriate