Model Cancellation Form

(Complete and return this form only if you wish to withdraw from the contract)

CROMA-PHARMA LIMITED
Suite 1, 3rd Floor
11 - 12 St. James's Square
London
United Kingdom
SW1Y 4LB

Telephone: +44 118 206 6513

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