(Complete and return this form only if you wish to withdraw from the contract)

To Caroline Hirons Limited, Balfour House, 741 High Road, London, England, N12 0BP. 

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