WITHDRAWAL FORM

(To be printed, completed and attached to the return package)

To the attention of:

PIANORI (FMV SRL)

Station Street 106 1640

Rhode-Saint-Genèse

Belgium

I/We (*) hereby notify you of my/our (*) withdrawal from the contract for the sale of the following item:

Ordered on (*) / Received on (*):

Name of consumer(s):

Address of consumer(s):

Reason(s) for withdrawal:

Date :

Signature of the consumer(s)

(only in case of paper notification)

(*) Delete as appropriate