# Model cancellation form

This form is optional. You can use another clear cancellation statement, without a portal account.

Complete and send this form only if you wish to cancel your contract.

**To:** Burnadette Marina Ilya Samir Ilies, trading as Learn Science With B  
10 Honeysuckle Road, Witham St Hughs, Lincoln, LN6 9ZG  
Email: burnie@learnsciencewithb.co.uk

I/We [*] hereby give notice that I/We [*] cancel my/our [*] contract for the supply of the following service:

Service: _______________________________________________

Ordered on: _____________________________________________

Name of consumer(s): _____________________________________

Address of consumer(s): __________________________________

_________________________________________________________

Signature of consumer(s), only if this form is notified on paper:

_________________________________________________________

Date: ___________________________________________________

[*] Delete as appropriate.