Terms of service
LEESICON.PL ONLINE STORE TERMS AND CONDITIONS
These Terms and Conditions of the LEESICON.PL Online Store have been prepared in accordance with the highest consumer protection standards.
Consumers may not waive any rights granted to them under applicable consumer protection laws. Any contractual provisions that are less favourable to the Consumer than the mandatory provisions of applicable law shall be deemed null and void, and the relevant statutory provisions shall apply instead.
Any ambiguity in the interpretation of these Terms and Conditions shall be resolved in favour of the Consumer.
1. GENERAL PROVISIONS
1.1.
The Online Store available at:
is operated by:
LEES ICON SPÓŁKA Z OGRANICZONĄ ODPOWIEDZIALNOŚCIĄ
ul. Sygnały 62/312
44-251 Rybnik
Poland
entered in the National Court Register (KRS) maintained by the District Court in Gliwice, 10th Commercial Division of the National Court Register, under registration number:
KRS No.: 0001240698
Tax Identification Number (NIP): 6423270684
REGON: 544712601
Share Capital: PLN 5,000.00, fully paid up.
1.1.1. Digital Services Act (DSA)
Regulation (EU) 2022/2065 of the European Parliament and of the Council of 19 October 2022 on a Single Market for Digital Services.
1.1.2.
All Products offered through the Online Store comply with the safety requirements set out in Regulation (EU) 2023/988 on General Product Safety (GPSR).
Products are assessed for compliance with the applicable product safety requirements.
1.1.3. Illegal Content
Any information that is contrary to European Union law or to the law of a Member State consistent with European Union law.
1.2.
These Terms and Conditions apply to both Consumers and Business Customers unless a specific provision expressly states otherwise.
1.3.
The Seller acts as the Data Controller of personal data.
Personal data are processed in accordance with the Privacy Policy available on the Online Store website.
1.4.
Each Product includes information regarding its country of origin.
Where Products are imported from outside the European Union, information concerning the manufacturer or importer is also provided.
1.5. Definitions
For the purposes of these Terms and Conditions:
Business Day means any day from Monday to Friday, excluding public holidays.
Registration Form means the electronic form enabling the creation of a Customer Account.
Order Form means the electronic service enabling the Customer to place an Order.
Customer means any natural person, legal entity or organisational unit placing an Order.
Civil Code means the Polish Civil Code of 23 April 1964, as amended.
Customer Account means the individual account assigned to the Customer within the Online Store.
Newsletter means the electronic service consisting of the delivery of commercial and marketing communications.
Back-in-Stock Notification means the electronic service informing Customers that a Product has become available again.
Product means women's clothing offered through the Online Store.
Terms and Conditions means this document.
Online Store means www.leesicon.pl
Seller means LEES ICON Sp. z o.o.
Sales Agreement means the agreement concluded between the Customer and the Seller for the sale of a Product.
Electronic Service means any service provided electronically through the Online Store.
User means any person using an Electronic Service.
Consumer Rights Act means the Polish Consumer Rights Act of 30 May 2014.
Order means the Customer's declaration of intent to conclude a Sales Agreement.
Digital Services Act (DSA) has the meaning specified in Section 1.1.1.
Illegal Content has the meaning specified in Section 1.1.3.
2. ELECTRONIC SERVICES PROVIDED THROUGH THE ONLINE STORE
2.1.
The following Electronic Services are available through the Online Store:
- Customer Account;
- Order Form;
- Newsletter;
- Back-in-Stock Notification;
- Contact Form.
2.1.1. Customer Account
A Customer Account may be created by completing both of the following steps:
- Completing the Registration Form; and
- Clicking the "Register" button.
The Registration Form requires the following information:
- e-mail address;
- password.
If the User does not yet have a Customer Account, one may also be created during the checkout process. In such case, the Customer Account will be created automatically upon placing the Order.
2.1.1.1. Duration and Deletion of the Customer Account
The Customer Account is provided free of charge for an indefinite period.
The User may delete the Customer Account at any time by sending a request to:
2.1.2. Contact Form
The Contact Form may be used by accessing the "Contact" page, completing the form and clicking "Send Message."
The following information is required:
- first name;
- last name;
- e-mail address;
- subject;
- message.
2.1.2.1. Nature of the Service
The Contact Form is provided free of charge as a one-time Electronic Service.
The service is completed upon submission of the message.
2.1.3. Order Form
Use of the Order Form begins when the first Product is added to the shopping cart.
An Order is placed after completing both of the following steps:
- completing the Order Form; and
- clicking the "PLACE ORDER & PAY" button.
Until the above button is clicked, the Customer may modify the information entered.
The following information is required when placing an Order:
- first and last name;
- address (street, building number, postal code, city and country);
- e-mail address;
- telephone number;
- Product details;
- quantity;
- delivery method;
- payment method.
Business Customers may additionally provide their company name.
2. ELECTRONIC SERVICES PROVIDED THROUGH THE ONLINE STORE
2.1.3.1. Nature of the Service
The Order Form is provided free of charge as a one-time Electronic Service.
The service terminates upon the successful placement of an Order or upon the Customer discontinuing the ordering process.
2.1.4. Newsletter
The Newsletter service may be activated by:
- selecting the appropriate checkbox when creating a Customer Account;
- selecting the appropriate checkbox within the Customer Account settings;
- selecting the appropriate checkbox during the checkout process.
2.1.4.1. Duration and Unsubscription
The Newsletter is provided free of charge for an indefinite period.
The User may unsubscribe from the Newsletter at any time by:
- sending a request to kontakt@leesicon.pl, or
- changing the relevant settings within the Customer Account.
2.1.5. Back-in-Stock Notification
This service is available for Products that are temporarily unavailable.
To subscribe to the notification, the User must:
- open the relevant Product page;
- enter their e-mail address;
- click the "Notify me when available" button.
Once the Product becomes available again, the User will automatically receive an e-mail notification.
2.1.5.1. Nature of the Service
The Back-in-Stock Notification service is provided free of charge for an indefinite period.
The User may cancel this service at any time by contacting:
2.2. Technical Requirements
To use the Online Store, the following minimum technical requirements must be met:
- a device with Internet access;
- an active e-mail account;
- an up-to-date web browser;
- enabled cookies;
- enabled JavaScript support.
2.3. User Obligations
The User agrees to:
- use the Online Store in compliance with applicable law, these Terms and Conditions and accepted standards of fair practice;
- respect the personal rights and intellectual property rights of third parties;
- provide accurate, complete and truthful information;
- refrain from providing or transmitting any unlawful content.
2.4. Complaints Regarding Electronic Services
Complaints concerning Electronic Services shall be handled in accordance with Section 7 of these Terms and Conditions.
3. CONCLUSION OF THE SALES AGREEMENT
3.1.
A Sales Agreement between the Customer and the Seller is concluded once the Customer places an Order using the Order Form referred to in Section 2.1.3 of these Terms and Conditions.
3.2.
All Product prices displayed in the Online Store are expressed in Polish Złoty (PLN) and include all applicable taxes.
The Customer is informed of the total price of the Order, including taxes, delivery charges and any additional costs, during the checkout process and immediately before placing the Order.
3.3. Procedure for Concluding the Sales Agreement
3.3.1.
The Sales Agreement is concluded upon the Customer placing an Order in accordance with Section 2.1.3 of these Terms and Conditions.
3.3.2.
Upon receipt of the Order, the Seller shall promptly:
- acknowledge receipt of the Order; and
- accept the Order for processing.
Confirmation shall be sent by e-mail to the address provided by the Customer when placing the Order.
The confirmation e-mail shall include, in particular:
- confirmation that the Order has been received;
- confirmation that the Order has been accepted for processing;
- confirmation that the Sales Agreement has been concluded.
The Sales Agreement is deemed concluded when the Customer receives the above confirmation e-mail.
3.4. Storage of the Sales Agreement
The content of the Sales Agreement is stored and made available by:
- publishing these Terms and Conditions on the Online Store website;
- sending the confirmation e-mail referred to in Section 3.3.2;
- storing the Order in the Online Store's IT system.
4. PAYMENT METHODS AND PAYMENT DEADLINES
4.1.
The Seller accepts the following payment methods:
4.1.1. Electronic Payments
Payments may be made via:
- Stripe (credit and debit cards);
- BLIK;
- Przelewy24.
4.1.2.
The payment methods currently available are displayed in the Payment Methods section of the Online Store.
4.1.3.
The following payment methods are not available:
- Cash on Delivery (COD);
- instalment payments;
- deferred payment services (including Klarna or PayPo);
- cash payments.
4.2. Payment Deadline
4.2.1.
Where the Customer chooses an electronic payment method, payment must be made immediately, and no later than 3 hours after placing the Order.
4.2.2.
If payment is not received within the above period, the Seller may automatically cancel the Order.
5. DELIVERY METHODS, SHIPPING COSTS AND DELIVERY TIMES
5.1.
Delivery of Products is subject to shipping charges unless otherwise agreed in the Sales Agreement.
Shipping costs, including transportation, delivery and postal charges, are displayed in the Shipping section of the Online Store and during the checkout process before the Customer places the Order.
5.2. Delivery Methods
The Seller offers the following delivery options:
5.2.1. Courier Delivery
Delivery by courier companies cooperating with the Seller, either directly or via the AlleKurier shipping platform.
5.2.2.
Delivery to InPost Parcel Lockers.
5.2.3.
Delivery via Pocztex (Polish Post).
5.3. Delivery Times
5.3.1.
Unless otherwise stated in the Product description or during the checkout process, the estimated delivery time is 5–7 Business Days.
5.3.2.
Where an Order contains Products with different delivery times, the delivery time for the entire Order shall correspond to the longest stated delivery period, which shall not exceed 7 Business Days.
5.3.3.
Where payment is made via Stripe, BLIK or Przelewy24, the delivery period shall commence on the date the payment is credited to the Seller's bank account.
6. PRODUCT SAFETY
6.1.
The Seller maintains a register of reports and complaints relating to the safety of Products offered through the Online Store.
If a Customer has any concerns regarding the safety of a purchased Product, they may contact the Seller by e-mail at:
or
All reports will be reviewed within 14 calendar days from the date of receipt.
6.2.
If a Product is found to present a safety risk, the Seller shall promptly inform affected Customers and provide detailed instructions regarding the return, repair or replacement procedure.
6.3.
Where a Product must be withdrawn from the market because it does not comply with applicable safety requirements, the Seller shall notify Customers of the appropriate course of action.
Detailed instructions regarding returns, replacement or repair will be sent to the e-mail address provided when placing the Order.
6.4.
The Seller operates a product monitoring system designed to identify potential safety risks associated with Products offered through the Online Store.
These measures are intended to ensure a high level of consumer safety.
6.5.
The Seller shall cooperate with the competent market surveillance authorities in accordance with applicable product safety legislation.
7. COMPLAINT PROCEDURE
7.1.
This Section governs the procedure for handling all complaints submitted to the Seller, including complaints relating to:
- Products;
- Sales Agreements;
- Electronic Services;
- other services provided by the Seller;
- the operation of the Online Store.
7.2. Submitting a Complaint
Complaints may be submitted:
7.2.1.
by e-mail to:
7.2.2.
through the Contact Form available on the Online Store website.
7.2.3.
in writing to:
LEES ICON Sp. z o.o.
ul. Sygnały 62/312
44-251 Rybnik
Poland
7.3. Returning a Product Under a Complaint
The Product being complained about may be returned to:
LEES ICON Sp. z o.o.
ul. Sygnały 62/312
44-251 Rybnik
Poland
7.4. Recommended Contents of a Complaint
To facilitate prompt handling, a complaint should include:
- information regarding the subject of the complaint, including the nature of the defect or non-conformity and the date on which it occurred;
- the Customer's preferred remedy, such as:
- bringing the Product into conformity with the Sales Agreement;
- a price reduction;
- withdrawal from the Sales Agreement;
- the Customer's contact details.
Failure to provide the above information shall not affect the validity of the complaint but may extend the time required for processing.
7.5. Change of Contact Details
If the Customer's contact details change while the complaint is being processed, the Customer should promptly notify the Seller.
7.6. Supporting Evidence
The Customer may attach supporting evidence to the complaint, including:
- photographs;
- documents;
- the Product concerned.
Where necessary, the Seller may request additional information or documentation required to assess the complaint.
7.7. Complaint Handling Time
The Seller shall respond to the complaint without undue delay, and in any event no later than 14 calendar days from the date of receipt.
If the Seller fails to respond within this period, the complaint shall be deemed accepted where required by applicable law.
7.8. Legal Basis of the Seller's Liability
7.8.1.
Complaints concerning Products purchased before 1 January 2023 shall be governed by the provisions of the Polish Civil Code relating to statutory warranty for defects (Articles 556–576 of the Civil Code).
For Customers who are not Consumers, the statutory warranty for defects is excluded.
7.8.2.
Complaints concerning Products purchased on or after 1 January 2023 shall be governed by the provisions of the Polish Consumer Rights Act relating to the conformity of goods with the contract (Articles 43a–43g).
7.8.3.
The rights described in this Section also apply to natural persons carrying on business activities where the Sales Agreement does not have a professional character for that person within the meaning of applicable Polish law.
7.9. Additional Information
Further information concerning the Seller's liability and Customers' rights is available in the Returns & Complaints section of the Online Store.
7.10. Commercial Guarantee
Certain Products may be covered by a manufacturer's guarantee or a commercial guarantee provided by the distributor.
Where applicable, the guarantee terms are set out in the guarantee certificate supplied with the Product.
8. ALTERNATIVE DISPUTE RESOLUTION (ADR)
8.1.
The use of out-of-court complaint handling or dispute resolution procedures is voluntary.
The information provided below is for informational purposes only and does not constitute the Seller's agreement to participate in such procedures.
8.2.
Consumers may, in particular:
8.2.1.
refer a dispute to a permanent consumer arbitration court;
8.2.2.
request mediation conducted by the Trade Inspection Authority;
8.2.3.
seek assistance from the competent municipal or district Consumer Ombudsman;
8.2.4.
use the European Commission's Online Dispute Resolution (ODR) Platform:
https://ec.europa.eu/consumers/odr
The ODR platform enables Consumers and traders established within the European Union to resolve disputes arising from online sales contracts electronically.
8.3. Additional Information
Further information regarding out-of-court dispute resolution procedures is available on the website of the Polish Office of Competition and Consumer Protection (UOKiK):
The Seller is not legally obliged to participate in alternative dispute resolution proceedings but may choose to do so voluntarily in individual cases.
9. RIGHT OF WITHDRAWAL
9.1.
A Consumer who has concluded a distance Sales Agreement has the right to withdraw from the Agreement within 14 days, without giving any reason and without incurring any costs other than those specified in Section 9.8 of these Terms and Conditions.
9.1.1.
The provisions of these Terms and Conditions concerning Consumers shall also apply to natural persons entering into an agreement directly related to their business activity, where it follows from the nature of the agreement that it is not of a professional nature for that person, in accordance with the applicable provisions of Polish law.
Such persons shall enjoy the same right of withdrawal as Consumers.
9.2. Withdrawal Period
The withdrawal period shall expire 14 days after:
- the day on which the Consumer, or a third party indicated by the Consumer (other than the carrier), acquires physical possession of the Product; or
- in the case of multiple Products delivered separately, the day on which the Consumer, or a third party indicated by the Consumer, acquires physical possession of the last Product.
9.3. Exercising the Right of Withdrawal
To exercise the right of withdrawal, the Consumer must notify the Seller of their decision by means of an unequivocal statement.
The notification may be submitted:
by e-mail:
or
by post to:
LEES ICON Sp. z o.o.
ul. Sygnały 62/312
44-251 Rybnik
Poland
The Consumer may use the Model Withdrawal Form attached as Appendix 1 to these Terms and Conditions, although its use is not mandatory.
9.4. Effects of Withdrawal
9.4.1.
If the Consumer validly withdraws from the Sales Agreement, the Seller shall reimburse all payments received from the Consumer, including the costs of the standard delivery method offered by the Seller.
Any additional costs resulting from the Consumer's choice of a delivery method other than the least expensive standard delivery option offered by the Seller shall not be reimbursed.
9.4.2.
The reimbursement shall be made without undue delay and, in any event, no later than 14 days from the date on which the Seller is informed of the Consumer's decision to withdraw from the Agreement.
The Seller may withhold reimbursement until the returned Product has been received or until the Consumer has supplied evidence of having returned the Product, whichever occurs first.
9.4.3.
The reimbursement shall be made using the same means of payment as those used by the Consumer for the original transaction, unless the Consumer has expressly agreed otherwise.
The Consumer shall not incur any fees as a result of such reimbursement.
9.5. Returning the Product
9.5.1.
The Consumer shall return the Product without undue delay and, in any event, no later than 14 days after notifying the Seller of the withdrawal.
The Product should be returned to:
LEES ICON Sp. z o.o.
ul. Sygnały 62/312
44-251 Rybnik
Poland
9.5.2.
The deadline shall be deemed met if the Consumer dispatches the Product before the expiry of the 14-day period.
9.5.3.
The Consumer shall bear the direct cost of returning the Product.
9.5.4.
For the Customer's convenience, the Seller also provides access to the Wygodne Zwroty (Convenient Returns) platform:
https://app.wygodnezwroty.pl/order
Use of this platform is entirely optional and does not affect the Consumer's statutory right of withdrawal.
9.5.5.
A Product may only be accepted for return if any security seal applied by the Seller remains intact.
If the security seal has been removed, damaged or tampered with, the Seller may assess whether the Product has been handled beyond what is necessary to establish its nature, characteristics and functioning.
Where permitted under applicable law, this may result in a reduction of the refund corresponding to the diminished value of the Product.
9.6. Consumer's Liability for Diminished Value
The Consumer shall be liable for any diminished value of the Product resulting from handling the Product in a manner exceeding what is necessary to establish its nature, characteristics and functioning.
9.7. Conditions Applicable to Returns at LEESICON.PL
A Product may be returned only if:
- all original tags remain attached;
- any security seal applied by the Seller remains intact;
- the Product shows no signs of use;
- the Product has not been stained, washed or damaged;
- all original components and accessories are included.
Where these conditions are not satisfied, the Seller may refuse the return or reduce the refund to reflect the diminished value of the Product, where permitted by applicable law.
9.8. Exceptions to the Right of Withdrawal
The right of withdrawal shall not apply, in particular, to contracts concerning:
- services that have been fully performed where performance began with the Consumer's prior express consent;
- Products manufactured according to the Consumer's specifications or clearly personalised;
- sealed Products which are not suitable for return for health protection or hygiene reasons once the seal has been broken after delivery.
10. PROVISIONS APPLICABLE TO BUSINESS CUSTOMERS
10.1.
This Section of the Terms and Conditions applies exclusively to Customers and Service Users who are not Consumers, namely those purchasing Products in connection with their business or professional activities.
10.2. Exclusion of Statutory Warranty
With respect to Customers who are not Consumers, the Seller's statutory liability for defects in the Product is excluded to the fullest extent permitted by applicable law.
10.3. Transfer of Risk
The risk of accidental loss of or damage to the Product passes to the Customer who is not a Consumer upon delivery of the Product to the carrier.
The Seller shall not be liable for any acts or omissions of the carrier.
10.4. Limitation of Liability
The Seller's liability towards a Customer who is not a Consumer shall be limited to the value of the relevant Order, unless mandatory provisions of applicable law provide otherwise.
In particular, the Seller shall not be liable for:
- loss of profits;
- indirect or consequential damages;
- losses resulting from interruption of the Customer's business activities.
10.5. Governing Jurisdiction
Any disputes arising between the Seller and a Customer who is not a Consumer shall be submitted to the court having jurisdiction over the Seller's registered office, namely the competent court in Rybnik, Poland.
10.6. VAT Invoices
10.6.1.
A Customer who is not a Consumer may request the issuance of a VAT invoice.
10.6.2.
All invoicing details must be provided accurately and in full when placing the Order.
10.6.3.
The Seller shall not be responsible for any incorrect or incomplete invoicing information provided by the Customer.
11. PRODUCT REVIEWS
11.1.
The LEESICON.PL Online Store provides a Product Review System enabling Customers to publish ratings, comments and reviews relating to purchased Products.
11.2.
Reviews may only be submitted by Customers who have actually purchased the relevant Product through the Online Store.
The Seller applies technical measures to verify that reviews originate from genuine purchasers, including, in particular:
- sending review invitations exclusively to the e-mail address used when placing the Order;
- linking the ability to submit a review to a specific Order number.
11.3.
The Seller does not publish sponsored, purchased or commissioned reviews.
All published reviews must originate from genuine Customers.
11.4.
The Seller does not moderate reviews with respect to their substantive content.
However, the Seller reserves the right to remove reviews that:
- contain unlawful content;
- infringe the personal rights of third parties;
- contain offensive language, spam or advertising;
- are unrelated to the relevant Product.
11.5.
Reviews are displayed on the relevant Product page either in chronological order or according to rating, depending on the system configuration of the Online Store.
11.6.
Except as provided in Section 11.4, the Seller does not alter or interfere with the content of Customer reviews.
12. ILLEGAL CONTENT AND OTHER CONTENT CONTRARY TO THESE TERMS AND CONDITIONS
12.1.
The User shall use the Online Store in accordance with applicable law, accepted standards of conduct and these Terms and Conditions.
The publication or transmission of unlawful content is strictly prohibited, including in particular:
- content that infringes European Union law or Polish law;
- content infringing the personal rights of third parties;
- offensive, abusive or hateful content;
- spam or unsolicited commercial communications;
- content infringing copyright or other intellectual property rights.
12.2. Reporting Illegal Content (DSA)
Any User may report content considered to be unlawful or otherwise inconsistent with these Terms and Conditions.
Reports may be submitted:
- by e-mail to: kontakt@leesicon.pl;
- via the Contact Form available on the Online Store website.
A report should include:
- a description of the allegedly unlawful content;
- the location of the content (for example, a URL);
- the reasons for the report;
- the reporting person's contact details (optional).
12.3. Procedure for Handling Reports
12.3.1.
The Seller shall review each report without undue delay, taking into account its obligations under the Digital Services Act (DSA).
12.3.2.
Where the Seller determines that the reported content is unlawful or otherwise violates these Terms and Conditions, appropriate measures may be taken, including:
- removal of the content;
- disabling access to the content;
- restricting the functionality of the User's Account;
- permanent deletion of the User's Account in the event of repeated violations.
12.3.3.
Where contact details have been provided, the Seller shall inform the reporting person of the outcome of the report.
12.4. Abuse of the Reporting Procedure
12.4.1.
Repeated, malicious or manifestly unfounded reports may result in restrictions on the User's ability to use the reporting mechanism.
12.4.2.
The Seller may refuse to process a report if it is incomplete or does not contain sufficient information to identify the reported content.
12.5. User Responsibility
12.5.1.
The User bears sole responsibility for any content published or transmitted through the Online Store.
12.5.2.
Where a User violates applicable law or these Terms and Conditions, the Seller reserves the right to pursue any legal remedies available, including claims for damages.
13. FINAL PROVISIONS
13.1.
Sales Agreements concluded through the LEESICON.PL Online Store are concluded in the Polish language.
13.2.
The recording, storage and provision of the content of the Sales Agreement shall be carried out in accordance with Section 3.4 of these Terms and Conditions.
13.3.
The Seller reserves the right to amend these Terms and Conditions for valid reasons, including in particular:
- changes in applicable legislation;
- changes to payment or delivery methods;
- changes to the Seller's business information;
- changes to the functionality of the Online Store.
13.4.
Customers and Users shall be informed of any amendments by publication of the updated Terms and Conditions on the Online Store website and, where applicable, by e-mail sent to the address associated with the Customer Account.
13.5.
Any amendments to these Terms and Conditions shall not affect the rights of Customers arising from Sales Agreements concluded before such amendments become effective.
13.6.
Any matters not governed by these Terms and Conditions shall be governed by:
- the Polish Civil Code;
- the Polish Consumer Rights Act;
- the Polish Act on the Provision of Electronic Services;
- Regulation (EU) 2023/988 on General Product Safety (GPSR);
- Regulation (EU) 2022/2065 on a Single Market for Digital Services (Digital Services Act – DSA).
13.7.
These Terms and Conditions shall enter into force on the date of their publication on the Online Store website.
APPENDIX 1
MODEL WITHDRAWAL FORM
(Complete and return this form only if you wish to withdraw from the Sales Agreement.)
Recipient:
LEES ICON Sp. z o.o.
ul. Sygnały 62/312
44-251 Rybnik
Poland
E-mail: zwroty@leesicon.pl
WITHDRAWAL FORM
I/We () hereby give notice that I/We () withdraw from the contract for the sale of the following Product(s):
....................................................................................................................
....................................................................................................................
Date of conclusion of the Agreement / Date of receipt of the Product:
....................................................................................................................
Consumer's full name:
....................................................................................................................
Consumer's address:
....................................................................................................................
....................................................................................................................
E-mail address or telephone number (optional):
....................................................................................................................
Consumer's signature (only if this form is submitted on paper):
....................................................................................................................
Date:
....................................................................................................................
(*) Delete as appropriate.