General Terms and Conditions
These General Terms and Conditions of DrDetoxBox were drafted
in consultation with the Consumentenbond [Consumer’s Association] in the context
of the Self-regulation Coordination Group [Coördinatiegroep Zelfreguleringsoverleg
CZ] of the Socioeconomic Council [Sociaal-ecomische Raad] and come into force on
1 June 2014.
Article 1 - Definitions
Article 2 - The Entrepreneur’s identity
Article 3 - Applicability
Article 4 - The offer
Article 5 - The agreement
Article 6 - Right of withdrawal
Article 7 - Consumer’s obligations during the reflection period
Article 8 - Exercising the Consumer’s right of withdrawal and the costs
Article 9 - Entrepreneur’s obligation in case of withdrawal
Article 10 - Exclusion of the right of withdrawal
Article 11 - The price
Article 12 - Compliance and extra guaranty
Article 13 - Delivery and execution
Article 14 - Continuing performance contract: duration, termination and extension
Article 15 - Payment
Article 16 - Complaints procedure
Article 17 - Disputes
Article 18 - Sector guarantee
Article 19 - Additional or varying provisions
Article 20 - Amendment to the General Terms and Conditions of Webshop Keurmerk
Article 1 – Definitions
In these Terms and Conditions, the following terms shall have the following
1. Additional agreement: an agreement in which the Consumer acquires
products, digital content and/or services with respect to a distance agreement
and these goods, digital content and/or services are delivered by the
Entrepreneur or a third party on the basis of an arrangement between this
third party and the Entrepreneur;
2. Reflection period: the period during which the Consumer may use his
right of withdrawal;
3. Consumer: the natural person who does not act for purposes related to
his/her commercial, trade, craft or professional activities;
4. Day: calendar day;
5. Digital content: data produced and delivered in digital form;
6. Continuing performance contract: a contract serving to deliver goods,
services and/or digital content in a given period;
7. Sustainable data carrier: any means, including email, that allow the
Consumer or the Entrepreneur to store information directed to him/her
personally in such a manner that makes future consultation and use possible
during a period that matches the purpose for which the information is
destined and which makes unaltered reproduction of the stored information
8. Right of withdrawal: the Consumer’s option not to proceed with the
distance agreement within the cooling-off period;
9. Entrepreneur: the natural of legal person who is a member of Stichting
Webshop Keurmerk and who provides products, (access to) digital content
and or services to Consumers at a distance;
10. Distance contract: a contract concluded by the Entrepreneur and the
Consumer within the scope of an organised system for distance selling
products, digital content and/or services, whereby exclusive or additional
use is made of one or more technologies of distance communication up to the
conclusion of the contract;
11. Standard form for withdrawal: the European standard form for
withdrawal included in Appendix 1;
12. Technology for distance communication: a means to be used for
concluding an agreement without the Consumer and the Entrepreneur being
together in the same place at the same time.
Article 2 – The Entrepreneur’s identity
Amsterdamseweg 511, 1181BS Amstelveen
Phone: +31 (0)202622126
E-mailadres: [email protected]
Article 3 – Applicability
1. These General Terms and Conditions apply to any offer from the Entrepreneur
and to any distance contract concluded by the Entrepreneur and the
2. Before concluding a distance contract, the Entrepreneur shall make the text of
these General Terms and Conditions available free of charge and as soon as
possible. If this is reasonably impossible, the Entrepreneur shall indicate in
what way the General Terms and conditions can be inspected and that they
will be sent free of charge if so requested, before the distant contract is
3. If the distance contract is concluded electronically, the text of these General
Terms and Conditions, in deviation from the previous section and before the
distance contract is concluded, may also be supplied to the Consumer
electronically in such a way that the Consumer can easily store it on a longterm
data carrier. If this is reasonably impossible, it will be specified where
the General Terms and Conditions can be viewed electronically and that they
will be sent to at the Consumer´s request free of charge, either via
electronic means or otherwise, before concluding the distance contract;
4. In the event that specific product or service condition apply in addition to
these General Terms and Conditions, the second and third paragraphs shall
apply accordingly, and in the event of contradictory terms and conditions, the
Consumer may always appeal to the applicable provision that is most
favourable to him/her.
Article 4 – The offer
1. If an offer is of limited duration or if certain conditions apply, it shall be
explicitly stated in the offer.
2. The offer contains a full and accurate description of the products, digital
content and/or services offered. The description is suitably detailed to enable
the Consumer to assess the products, or services and/or digital content
adequately. If the Entrepreneur makes use of pictures, they are truthful
images of the products and/or services provided. Obvious errors or mistakes
in the offer do not bind the Entrepreneur.
3. All offers contain such information that it is clear to the Consumer what rights
and obligations are attached to accepting the offer.
Article 5 – The contract
1. Subject to the provisions in paragraph 4, the contract becomes valid when the
Consumer has accepted the offer and fulfilled the terms and conditions set.
2. If the Consumer accepted the offer via electronic means, the Entrepreneur
shall promptly confirm receipt of having accepted the offer via electronic
means. As long as the receipt of said acceptance has not been confirmed, the
Consumer may repudiate the contract.
3. If the contract is concluded electronically, the Entrepreneur will take
appropriate technical and organisational security measures for the electronic
data transfer and ensure a safe web environment. If the Consumer can pay
electronically, the Entrepreneur shall observe appropriate security measures.
4. The Entrepreneur may, within the limits of the law, gather information about
Consumer’s ability to fulfil his payment obligations, and all facts and factors
relevant to responsibly concluding the distance contract. If, acting on the
results of this investigation, the Entrepreneur has sound reasons for not
concluding the contract, he is lawfully entitled to refuse an order or request
supported by reasons, or to attach special terms to the implementation.
5. Before delivering the product, the Entrepreneur shall send the following
information along with the product, the service or the digital content in writing
or in such manner that the Consumer can store it in an accessible manner on
a long-term data carrier:
a. the visiting address of the Entrepreneur´s business establishment where
the Consumer may get into contact with any complaints;
b. the conditions on which and the manner in which the Consumer may
exercise the right of withdrawal, or, as the case may be, clear information
about his being exempted from the right of withdrawal;
c. the information corresponding to existing after-sales services and
d. The price including all taxes of the product, service or digital content,
where applicable the delivery costs and the way of payment, delivery or
implementation of the distance contract;
e. the requirements for cancelling the contract if the contract has a duration
of more than one year or for an indefinite period of time.
f. the standard form for withdrawal if the Consumer has the right of
6. In case of a continuing performance contract, the stipulation in the previous
paragraph only applies to the first delivery.
Article 6 – Right of withdrawal
In case of products:
1. The Consumer can repudiate a purchase contract for a product without giving
reasons for a period of reflection of at least 14 days. The Entrepreneur may
ask the Consumer about the reason for the withdrawal but cannot force
him to state his reason(s).
2. The reflection period referred to in sub-clause 1 starts on the day the product
is received by the Consumer or by a third party appointed by him in advance
and who is not the carrier, or
a. if the Consumer ordered several products in the same order: the day on
which the Consumer or a third party appointed by him received the
last product. The Entrepreneur may refuse an order of several products
with different delivery dates provided that he clearly informs the
Consumer prior to the order process.
b. in case the delivery of a product consists of several batches or parts:
the day on which the Consumer or a third party appointed by him
received the last batch or the last part.
c. in case of an agreement about regular delivery of products during a
given period: the day on which the Consumer or a third party appointed
by him received the first product.
In case of services and digital content that is not delivered on a physical carrier:
3. The Consumer can terminate an agreement for services or an agreement
for delivery of digital content that is not delivered on a physical carrier
without giving reasons during at least 14 days. The Entrepreneur may ask
the Consumer about the reason for the withdrawal but cannot force him to
state his reason(s).
4. The reflection period referred to in Article 3 starts on the day following the
conclusion of the agreement.
Extended reflection period for products, services and digital content that has not
been delivered on a physical carrier in case no information is given about the right
5. If the Entrepreneur has not provided the Consumer with the legally required
information about the right of withdrawal or has not provided the standard
form for withdrawal, the reflection period expires twelve months after the
end of the original reflection period in accordance with the reflection period
determined in the previous sub-clauses of this Article.
6. If the Entrepreneur provided the Consumer with the information referred
to in the previous article within twelve months after the starting day of the
original period of reflection, the period of reflection expires 14 day after the
day on which the Consumer received the information.
Article 7 – Consumer’s obligations during the time of reflection
1. During this period, the Consumer shall handle the product and the packaging
with care. The Consumer shall only unpack or use the product to the extent
necessary for establishing the nature, the characteristics and the effect of the
product. The guiding principle is that the Consumer may only handle and
inspect the product in the manner in which one is allowed to handle a product
in a shop.
2. The Consumer is only liable for the decrease in value of the product that is
caused by the way of handling the product which went further than
allowed in sub-section 1.
3. The Consumer is not liable for the decrease in value of the product if the
Entrepreneur has not provided him with all legal information about the right of
withdrawal before concluding the Agreement.
Article 8 – Exercising the Consumer’s right of withdrawal and the costs
1. If the Consumer exercises his right of withdrawal he shall notify the
Entrepreneur unambiguously with the standard form for withdrawal within the
period of reflection.
2. The Consumer shall return the product or deliver it to (the authorized
representative of) the Entrepreneur as soon as possible but within 14 days
counting from the day following the notification referred to in sub-clause 1.
This need not be done if the entrepreneur offered to collect the product
himself. The Consumer observed the period of returning the product in any
event if the product is returned before the expiration of the period of
3. The Consumer shall return the product with all delivered accessories and if
reasonably possible in the original state and packing and in conformity with
reasonable and clear instructions given by the Entrepreneur.
4. The risk and the burden of proof for the correct and timely exercise of the
right of withdrawal fall on the Consumer.
5. The Consumer shall bear the direct costs of returning the product. If the
Entrepreneur has not reported that the Consumer has to bear these costs or if
the Entrepreneur pointed out that he will bear the costs himself, the
Consumer need not pay the cost of returning the product.
6. If the Consumer withdraws after having first explicitly requested that the
performance of a service or the supply of gas, water or electricity having not
been made ready for sale not be started in a limited volume or given quantity
during the period of reflection, the Consumer shall pay the Entrepreneur an
amount that is equal to the part of the obligation already performed at the
time of withdrawal as compared with the full compliance of the obligation.
7. The Consumer does not bear the costs for performing services for the supply
of water, gas or electricity that had not been made ready for sale in a limited
volume or quantity, or for the supply of district heating if
a. the Entrepreneur has not provided the Consumer with the statutorily
required information about the right of withdrawal, the compensation of
costs in case of withdrawal or the standard form for withdrawal, or
b. if the Consumer has not explicitly requested that the performance of
the service or the supply of gas, water and electricity or district heating
be started during the period of reflection.
8. The Consumer does not bear any cost for the full or partial delivery of
digital content not stored on a physical carrier if
a. prior to the delivery, he has not explicitly consented to start
performance of the agreement before the end of the period of reflection;
b. he did not acknowledge to lose his right of withdrawal when giving
c. the Entrepreneur failed to confirm the Consumer’s statement.
9. If the Consumer exercises his right of withdrawal, all additional agreements
end by operation of law.
Article 9 – Entrepreneur’s obligations in case of withdrawal
1. If the Entrepreneur makes the notification of withdrawal by electronic means
possible, he shall promptly send a return receipt.
2. The Entrepreneur shall reimburse all payments made by the Consumer,
including any delivery costs that the Consumer may charge for the returned
product, as soon as possible but within 14 days following the day on which
the Consumer notified him of the withdrawal. Unless the Entrepreneur offers
to collect the product himself, he can wait with paying back until having
received the product or until the Consumer proved that he returned the
product, whichever occurs first.
3. The Entrepreneur shall make use of the same means of payment that the
Consumer used, unless the Consumer consents to another method. The
reimbursement is free of charge for the Consumer.
4. If the Consumer opted for a more expensive method of delivery instead of the
cheapest standard delivery, the Entrepreneur need not reimburse the
additional costs for the more expensive method.
Article 10 - Exclusion of the right of withdrawal
The Entrepreneur can exclude the following products and services from the right of
withdrawal but only if the Entrepreneur notified this clearly when making the offer
or at any rate in good time before concluding the agreement:
1. Products or services with a price that is subject to fluctuations in the
financial market on which the Entrepreneur has no influence and which may
occur within the period of withdrawal;
2. Agreements that are concluded during a public auction. A public auction is
defined as a selling method whereby the Entrepreneur offers products, digital
content and/or services to the Consumer who is personally present or has the
possibility to be personally present at the auction under the direction of an
auctioneer and whereby the successful bidder is obliged to purchase the
products, the digital content and/or the services.
3. Services agreements, after full performance of the service, but only if
a. the performance started with the Consumer’s explicit prior consent; and
b. the Consumer stated that he will lose his right of withdrawal as soon as
the Entrepreneur has fully performed the agreement.
4. Services agreements for making accommodation available when a certain
period of implementation is provided and other than for residential
purposes, goods transports, car rental services and catering;
5. Agreements related to leisure activities when a certain date or period of
performance is arranged in the agreement;
6. Products manufactured in accordance with the Consumer’s specifications
which are not prefabricated and which are produced on the basis of a
Consumer’s individual choice or decision or which are intended for a specific
7. Perishable products or products with a limited durability.
8. Sealed products which are for health or hygiene reasons not suitable for being
returned and of which the seal was broken;
9. Products which for their nature are irreversibly mixed with other products;
10. Alcoholic drinks of which the price has been agreed upon at the conclusion of
the agreement but of which the delivery can take place only after 30 days,
and whose real value depends on fluctuations in the market which the
Entrepreneur cannot affect.
11. Sealed audio and video recordings and computer programs of which the seals
were broken after delivery;
12. Newspapers, periodicals or magazines, with the exception of subscriptions to
13. The delivery of digital content other than on a physical carrier, but only if:
a. the performance was started with the Consumer’s explicit prior
b. the Consumer stated that he will lose his right of withdrawal by doing
Article 11 - The price
1. The prices of the products and/or services provided shall not be raised during
the validity period given in the offer, subject to changes in price due to
changes in VAT rates.
2. Contrary to the previous paragraph, the Entrepreneur may offer products or
services whose prices are subject to fluctuations in the financial market that
are beyond the Entrepreneur’s control, at variable prices. The offer will state
the possibility of being subject to fluctuations and the fact that any indicated
prices are target prices.
3. Price increases within 3 months after concluding the contract are permitted
only if they are the result of new legislation.
4. Price increases from 3 months after concluding the contract are permitted
only if the Entrepreneur has stipulated it and
a. they are the result of legal regulations or stipulations, or
b. the Consumer has the authority to cancel the contract before the day on
which the price increase starts.
5. All prices indicated in the provision of products or services are including VAT.
Article 12 – Performance of an agreement and extra Guarantee
1. The Entrepreneur guarantees that the products and/or services comply with
the contract, with the specifications listed in the offer, with reasonable
requirements of usability and/or reliability and with the existing statutory
provisions and/or government regulations on the day the contract was
concluded. If agreed, the Entrepreneur also guarantees that the product is
suitable for other than normal use.
2. An extra guarantee offered by the Entrepreneur, his Supplier, Manufacturer or
Importer shall never affect the rights and claims the Consumer may exercise
against the Entrepreneur about a failure in the fulfilment of the Entrepreneur’s
obligations if the Entrepreneur has failed in the fulfilment of his part of the
3. ‘Extra guarantee’ is taken to mean each obligation by the Entrepreneur, his
Supplier, Importer or Manufacturer in whom he assigns certain rights or
claims to the Consumer that go further than he is legally required in case he
fails in the compliance with his part of the agreement.
Article 13 – Delivery and execution
1. The Entrepreneur shall exercise the best possible care when booking orders
and executing product orders and when assessing requests for the
provision of services.
2. The place of delivery is at the address given by the Consumer to the
3. With due observance of the stipulations in Article 4 of these General Terms
and Conditions, the Entrepreneur shall execute accepted orders with
convenient speed but at least within 30 days, unless another delivery period
was agreed on. If the delivery has been delayed, or if an order cannot be
filled or can be filled only partially, the Consumer shall be informed about this
within one month after ordering. In such cases, the Consumer is entitled to
repudiate the contract free of charge and with the right to possible
4. After repudiation in conformity with the preceding paragraph, the
Entrepreneur shall return the payment made by the Consumer promptly but
at least within 30 days after repudiation.
5. The risk of loss and/or damage to products will be borne by the Entrepreneur
until the time of delivery to the Consumer or a representative appointed in
advance and made known to the Consumer, unless explicitly agreed
Article 14 – Continuing performance agreements: duration, termination
1. The Consumer may at all times terminate a contract that was concluded for
an indefinite time and which extends to the regular delivery of products
(including electricity) or services, with due observance of the termination
rules and subject to not more than one month’s notice.
2. The Consumer may at all times terminate a contract that was concluded for a
specific time and which extends to the regular delivery of products (including
electricity) or services at the end of the specific period, with due observance
of the termination rules and a subject to not more than one month’s notice.
3. The Consumer can cancel the agreements mentioned in the preceding
- at any time and not be limited to termination at a particular time or in a
- at least in the same way as they were concluded by him;
- at all times with the same notice as the Entrepreneur stipulated for
4. An agreement concluded for a definite period which extends to the regular
delivery of products (including electricity) or services may not be
automatically extended or renewed for a fixed period.
5. Notwithstanding the preceding paragraph, a contract for a definite period
which extends to the regular delivery of dailies, newspapers, weekly
newspapers and magazines, may tacitly be renewed for specific period of
three months at the most if the Consumer can terminate this extended
agreement towards the end of the extension with a notice of one month at the
6. An agreement concluded for a definite period and which extends to the
regular delivery of products or services may only be extended tacitly for an
indefinite period if the Consumer can cancel it at any time with a notice of one
month. The notice is three months at the most in vase the contract is about
a delivery of dailies, newspapers and weeklies and magazines occurring
regularly but less than once a month.
7. An agreement with limited duration of regular delivery of trial dailies,
newspapers, weeklies and magazines (trial or introductory subscription) is not
renewed tacitly and ends automatically after the trial or introductory period.
8. If the duration of a contract is more than one year, the Consumer may
terminate the contract at any time after one year with a notice of not more
than one month, unless reasonableness and fairness resist the termination
before the end of the agreed term.
Article 15 – Payment
1. Unless otherwise stipulated in the agreement or in the additional conditions,
the amounts to be paid by the Consumer must be settled within 14 days after
the period of reflection, or if there is no period of reflection within 14 days
after concluding the agreement. In case of an agreement to provide a service,
this period starts on the day that the Consumer received the confirmation of
2. When selling products to Consumers, it is not permitted to negotiate an
advance payment of more than 50% in the General Terms and Conditions.
If an advance payment was agreed, the Consumer may not assert any right
regarding the execution of the order in question or the service(s) in
question before making the agreed advance payment.
3. The Consumer has the duty to inform the Entrepreneur promptly of possible
inaccuracies in the payment details that were given or specified.
4. In case the Consumer has not complied with his payment obligation(s) in
time, and the Entrepreneur has pointed out to him that the payment was late
and allowed the Consumer a period of 14 days to comply with the payment
obligations, the Consumer is to pay the statutory interest on the amount
payable and the Entrepreneur is entitled to charge the Consumer with any
extrajudicial collection costs. These extrajudicial collection costs amount to no
more than 15% for outstanding amounts up to € 2,500, 10% for the following
€ 2,500 and 5% for the following € 5000, with a minimum of € 40. The
Entrepreneur may deviate from the aforementioned amounts and percentages
in favour of the Consumer.
Article 16 – Complaints procedure
1. The Entrepreneur shall have a sufficiently notified complaints procedure in
place, and shall handle the complaint in accordance with this complaint
2. Complaints about the performance of the contract shall be submitted fully and
clearly described to the Entrepreneur within a reasonable time after the
Consumer discovered the defects
3. The complaints submitted to the Entrepreneur shall be replied within a period
of 14 days after the date of receipt. Should a complaint require a foreseeable
longer time for handling, the Entrepreneur shall respond within 14 days with a
notice of receipt and an indication when the Consumer can expect a more
4. A complaint about the Entrepreneur’s product, service or after-sales service
can also be submitted to Stichting Webshop Keurmerk with a complaints form
given in the Consumer Page of the website www.Stichting Webshop
Keurmerk. org. The complaint will then be sent to the Entrepreneur in
question and to Stichting Webshop Keurmerk.
5. If the complaint cannot be solved in joint consultation within a reasonable
time or within 3 months after submitting the complaint, there will be a dispute
that is open to the dispute settlement rules.
Article 17 - Disputes
1. Contracts between the Entrepreneur and the Consumer to which these
General Terms and Conditions apply, are exclusively governed by Dutch law.
2. With due observance of the provisions set out below, the disputes between
the Consumer and the Entrepreneur about the formation or the performance
of contracts related to products or services that the Entrepreneur must deliver
or has already delivered can be submitted by both the Consumer and the
Entrepreneur to Geschillencommissie Webshop, Postbus 90600, 2509 LP,
The Hague (Den Haag) (www.sgc.nl).
3. A dispute is handled by the Disputes Committee [Geschillencommissie] only if
the Consumer submitted his/her complaint to the Entrepreneur within a
4. The dispute must have been submitted in writing to the Geschillencommissie
Webshop within three months after arising of the dispute.
5. If the Consumer wishes to submit a dispute to the Geschillencommissie, the
Entrepreneur is bound by this choice. When the Entrepreneur wishes to file
the dispute to the Geschillencommissie, the Consumer must speak out in
writing within five weeks after a written request made by the Entrepreneur
whether he so desires or wants the dispute to be dealt with by the competent
court. If the Entrepreneur has not heard of the Consumer’s option within the
period of five weeks, the Entrepreneur is entitled to submit the dispute to the
6. The Geschillencommissie’s decision will be made under the conditions as set
out in the rules of the Arbitration Commission
A decision made by the Geschillencommissie is a binding advice.
7. The Disputes Committee will not handle a dispute or will discontinue handling
it if the Entrepreneur is granted a moratorium, goes bankrupt or actually
ended his business activities before the Commission has handled a dispute at
the hearing and delivered a final award.
8. If in addition to the Geschillencommissie Webshop another disputes
committee recognised by or affiliated with the Stichting Geschillencommissies
voor Consumentenzaken (SGC) [Foundation for Consumer Complaints
Committees] or the Klachteninstituut Financiële Dienstverlening (Kifid)
[Financial Services Complaints Board] is competent, the disputes that are
mainly related to sales methods or distance services, the
Geschillencommissie Webshop Keurmerk is preferably competent, and for all
other disputes, the disputes committee recognised by and affiliated with the
SGC or Kifid is competent.
Article 18 –Guarantee by this branch of industry
1. Webshop Keurmerk guarantees that its members follow the binding advice of
the Disputes Committee Webshop unless the member decides to send the
binding opinion for review to the Court within two months. This guarantee
revives if after review by the Court the binding opinion has been
confirmed and the judgement has become final. Webshop Keurmerk will pay
this amount to the Consumer up to €10,000 per binding opinion. € 10,000
will be paid if the amount exceeds €10,000 per binding advice. As to the
remaining amount, Webshop Keurmerk has an obligation to try to ensure
that members comply with the binding advice.
2. For the application of this guarantee, it is required that the Consumer submit
a written appeal to Webshop Keurmerk and that he assign the claim against
the Entrepreneur to the Stichting Webshop Keurmerk. If the claim against
the Entrepreneur exceeds €10,000, the Consumer will be offered to assign the
claim on for the excess amount to Stichting Webshop Keurmerk, after which
this organisation, in its own name and at its own expense, shall try to get
payment and fulfilment of these rights to compensate the Consumer.
Article 19 - Additional provisions or derogations
Additional provisions of and/or derogations from these General Terms and
Conditions should not be to the Consumer’s detriment and must be put in writing or
recorded in such a way that the Consumer can store them in an accessible manner
on a long-term data carrier.
Article 20 – Amendments to the General Terms and Conditions of
Stichting Webshop Keurmerk
1. These General Terms and Conditions will not be changed other than in
consultation with the Consumentenbond (Consumers’ Association).
2. Amendments to these Terms and Conditions are valid only after being
published in the appropriate way, provided that in case of appropriate
amendments, the provision that is most favourable for the Consumer shall
prevail during the validity of an offer.
Address Stichting Webshop Keurmerk:
Willemsparkweg 193, 1071 HA Amsterdam.
Appendix I: Standard form for withdrawal
Standard Form for Withdrawal
(Complete this form and return it only when you want to revoke the
- To: [Entrepreneur’s name]
[Entrepreneur’s geographic address]
[Entrepreneur’s fax number, if available]
[Entrepreneur’s email address or electronic address]
- I/We hereby inform you that I/we wish to revoke our agreement
on the sale of the following products: [specification of the
the delivery of the following digital content [specification of the digital
the performance of the following service [specification of the
- Ordered on*/received on* [date of ordering the services or receiving
- [Consumer’s name]
- [Consumer’s address]
- [Consumer’s signature] (only when this form is submitted on paper)
*) Delete and/or complete where appropriate.