Please complete and return this form only if you wish to withdraw from your contract with Us.

To:	Mariagalerias.com Unit 113998, PO Box 6945, London, W1A 6US Email: orders@mariagalerias.com
I/We[*] hereby give notice that I/we[*] cancel my/our[*] contract for the sale of the following goods.
Order Number/Reference:
Description of Goods:
Ordered on :
Received on:
Detailed reason for the cancellation:
Name of Consumer(s):
Address of Consumer(s):
Signature of Consumer(s): (only if this form is notified on paper)
Date:

[*] Delete as appropriate