Withdrawal slip

To be completed where applicable and returned by email to pauline@domainedugout.com or by letter to the administrative and commercial address of DOMAINE DU GOUT - 67 rue des Godrans DIJON (21000).

I, the undersigned), ............................................ ............................................ hereby declares and in compliance with the legislation on distance selling, use within the legal period of my right to renounce the purchase that is the subject of the order form.

Nature of the goods or service *: ......................................... .................................................. .........................

Date of the order (appear in your order confirmation email) *: .................................. ........................

Order number (appear in your order confirmation email) *: ................................... ............................

Customer address *: ............................................. .................................................. ...........................................

Reason (optional): ............................................. .................................................. .................................................. ............

Date *: ............................................... .....

Signature *: ............................................... .......................................

Bank details (To be completed if you wish to reimburse by transfer):

IBAN: _______ _______ _______ ________ _______ _______ _______

* Required fields