******************************************************************************

Order cancellation

Conditions:

- Complete and sign this form

- Send it by registered letter to the following address:

SAGEMCOM AUSTRIA GmbH

Gutheil Schoder-Gasse 17

1230 Vienna – Austria

- Return the completed and signed form no later than 14 days after the date of the order delivery . If the deadline falls on Saturday or Sunday or on a Bank holiday, then send it on the next working day.

I the undersigned declare cancelling my order hereafter:

Product & model: ________________________________________________________

_______________________________________________________________________

Order date: _____________________________________________________________

Order number: __________________________________________________________

Customer name: _________________________________________________________

Customer address: ________________________________________________________

Customer Signature: _______________________________________________________