WITHDRAWAL FORM

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

C R U B A Berlin GmbH & Co. KG

Auguststr. 28

10117 Berlin

Telefax +49 30 260 766 79

I hereby give notice that I withdraw from my contract of sale of the

following goods:

..............................................................................

.............................................................................. article name, size, price

goods ordered:

............................. date

goods received:

............................. date

name and address of the customer

.............................

............................. date

……………………………………………. signature of the customer