ONLINE PURCHASE WITHDRAWAL FORM (Complete and return this forms only if you wish to withdraw from your contract of sale) I hereby give notice that I cancel the contract that I concluded concerning the purchase of the following jewel (s): Description – Reference: Name SURNAME: Email Address: Address: Post Code: City: Country: Custumer Number: Date of purchase: Order Number: Invoice Number: Goods received on: Date of Withdrawal: Comment on your withdrawal: In accordance with legal provisions (article L.221-18 and following of the French Consumer Code), please refund my payment (in XPF) representing the total amount of my order here above mentioned, as soon as you receive the jewel (s) returned on by registered mail, at my own expense, to the following address: SARL PERLE MON AMOUR B.P. 21286 98713 PAPEETE – TAHITI Polynésie Française Email: perlemonamour@mail.pf Phone: +68987770232