General terms and conditions established in consultation with the consumer association
Consultation framework SER coordination group self-regulation consultation
These General Terms and Conditions of Stichting Webshop Keurmerk have been drawn up in consultation with the Consumers' Association within the framework of the Coordination Group Self-Regulation Consultation (CZ) of the Social and Economic Council and will come into effect on 1 June 2014.
These General Terms and Conditions will be used by all members of the Stichting Webshop Keurmerk with the exception of financial services as referred to in the Financial Supervision Act and insofar as these services are supervised by the Netherlands Authority for the Financial Markets.
Article 1 - Definitions
Article 2 - Identity of the entrepreneur
Article 3 - Applicability
Article 4 - The offer
Article 5 - The agreement
Article 6 - Right of withdrawal
Article 7 - Obligations of the consumer during the reflection period
Article 8 - Exercise of the right of withdrawal by the consumer and costs thereof
Article 9 - Obligations of the entrepreneur in the event of withdrawal
Article 10 - Exclusion right of withdrawal
Article 11 - The price
Article 12 - Performance and additional guarantee
Article 13 - Delivery and execution
Article 14 - Duration transactions: duration, cancellation and extension
Article 15 - Payment
Article 16 - Complaints procedure
Article 17 - Disputes
Article 18 - Industry guarantee
Article 19 - Additional or different provisions
Article 20 - Amendment of the general terms and conditions of Stichting Webshop Keurmerk
Article 1 - Definitions
In these terms and conditions, the following definitions apply:
1. Supplementary agreement: an agreement whereby the consumer acquires products, digital content and/or services in connection with a distance contract and these items, digital content and/or services are supplied by the entrepreneur or by a third party on the basis of a agreement between the third party and the entrepreneur;
2. Cooling-off period: the period within which the consumer can make use of his right of withdrawal;
3. Consumer: the natural person who does not act for purposes related to his trade, business, craft or profession;
4. Day: calendar day;
5. Digital content: data produced and supplied in digital form;
6. Duration agreement: an agreement that extends to the regular delivery of goods, services and/or digital content during a certain period;
7. Durable data carrier: any tool - including e-mail - that enables the consumer or entrepreneur to store information that is personally addressed to him in a way that future consultation or use during a period that is tailored to the purpose for which the information is intended, and which allows unaltered reproduction of the stored information;
8. Right of withdrawal: the consumer's option to cancel the distance contract within the cooling-off period;
9. Entrepreneur: the natural or legal person who is a member of Stichting Webshop Keurmerk and who offers products, (access to) digital content and/or services to consumers at a distance;
10. Distance contract: an agreement that is concluded between the entrepreneur and the consumer
in the context of an organized system for distance selling of products, digital content and/or services, whereby up to and including the conclusion of the agreement exclusively or partly one or more remote communication techniques are used;
11. Model withdrawal form: the European model withdrawal form included in Appendix I of these terms and conditions;
12. Technology for distance communication: means that can be used for concluding an agreement, without the consumer and entrepreneur having to meet in the same room at the same time;
Article 2 – Identity of the entrepreneur
Trade name: Pharmacy Outlet
Company: RUBOLI B.V.
Business address: Nies van der Schansstraat 4 c, 5161CE, Sprang-Capelle, The Netherlands
Phone number:+31 (0)88 – 011 11 73
Opening hours: from 9 a.m. to 5 p.m.
E-mail address: [email protected]
Chamber of Commerce number: 67503926
VAT ID number: NL857034522B01
If the activity of the entrepreneur is subject to a relevant licensing system: the data about the supervisory authority (does not apply).
If the entrepreneur practices a regulated profession:
the professional association or organization to which he is affiliated (does not apply); the professional title, the place in the EU or the European Economic Area where it was awarded (does not apply); a reference to the professional rules that apply in the Netherlands and indications where and how these professional rules are accessible (does not apply).
Article 3 – Applicability
1. These general terms and conditions apply to every offer from the entrepreneur and to every
distance contract concluded between the entrepreneur and consumer.
2. Before the distance contract is concluded, the text of these general terms and conditions is made
available to the consumer. If this is not reasonably possible, the entrepreneur will indicate before the
distance contract is concluded how the general terms and conditions can be viewed at the
entrepreneur and that they will be sent free of charge as soon as possible at the request of the
3. If the distance contract is concluded electronically, notwithstanding the previous paragraph and
before the distance contract is concluded, the text of these general terms and conditions can be
made available to the consumer electronically in such a way that it is consumer can be stored in a
simple way on a durable data carrier. If this is not reasonably possible, before the distance contract
is concluded, it will be indicated where the general terms and conditions can be consulted
electronically and that they will be sent free of charge at the request of the consumer electronically
4. In the event that specific product or service conditions apply in addition to these general terms and
conditions, the second and third paragraphs apply mutatis mutandis and the consumer can always
invoke the applicable provision that is most convenient for him in the event of conflicting terms and
conditions. is favorable.
Article 4 – The offer
1. If an offer has a limited period of validity or is made subject to conditions, this will be explicitly stated
in the offer.
2. The offer contains a complete and accurate description of the products, digital content and/or
services offered. The description is sufficiently detailed to enable a proper assessment of the offer by
the consumer. If the entrepreneur uses images, these are a true representation of the products,
services and/or digital content offered. Obvious mistakes or errors in the offer are not binding on the
3. Each offer contains such information that it is clear to the consumer what rights and obligations are
attached to the acceptance of the offer.
Article 5 – The agreement
1. Subject to the provisions of paragraph 4, the agreement is concluded at the time of acceptance by the consumer of the offer and the fulfillment of the associated conditions.
2. If the consumer has accepted the offer electronically, the entrepreneur will immediately confirm receipt of the acceptance of the offer electronically. As long as the receipt of this acceptance has not been confirmed by the entrepreneur, the consumer can dissolve the agreement.
3. If the agreement is concluded electronically, the entrepreneur will take appropriate technical and organizational measures to secure the electronic transfer of data and ensure a safe web environment. If the consumer can pay electronically, the entrepreneur will take appropriate security measures.
4. Within legal frameworks, the entrepreneur can inform himself whether the consumer can meet his payment obligations, as well as all those facts and factors that are important for a responsible conclusion of the distance contract. If, on the basis of this investigation, the entrepreneur has good reasons not to enter into the agreement, he is entitled to refuse an order or request with reasons, or to attach special conditions to the execution.
5. The entrepreneur will send the following information to the consumer at the latest when the product, service or digital content is delivered, in writing or in such a way that it can be stored by the consumer in an accessible manner on a durable data carrier:a. the visiting address of the establishment of the entrepreneur where the consumer can go with complaints;b. the conditions under which and the manner in which the consumer can make use of the right of withdrawal, or a clear statement regarding the exclusion of the right of withdrawal;c. the information about warranties and existing after-sales service;d. the price including all taxes of the product, service or digital content; to the extent applicable, the costs of delivery; and the method of payment, delivery or performance of the distance contract;e. the requirements for termination of the agreement if the agreement has a duration of more than one year or is of indefinite duration;f. if the consumer has a right of withdrawal, the model withdrawal form.
6. In the case of a long-term transaction, the provision in the previous paragraph only applies to the first delivery.
Article 6 – Right of withdrawal
1. The consumer can dissolve an agreement with regard to the purchase of a product during a reflection period of at least 14 days without stating reasons. The entrepreneur may ask the consumer for the reason for withdrawal, but not oblige him to state his reason(s).
2. The reflection period referred to in paragraph 1 starts on the day after the consumer, or a third party designated by the consumer in advance, who is not the carrier, has received the product, or:
a. if the consumer has ordered several products in the same order: the day on which the consumer, or a third party designated by him, has received the last product. The entrepreneur may, provided he has clearly informed the consumer about this prior to the ordering process, refuse an order for several products with different delivery times.
b. if the delivery of a product consists of several shipments or parts: the day on which the consumer, or a third party designated by him, has received the last shipment or the last part;
c. in the case of agreements for regular delivery of products during a certain period: the day on which the consumer, or a third party designated by him, has received the first product.
For services and digital content that is not provided on a tangible medium:
3. The consumer can dissolve a service agreement and an agreement for the supply of digital content
that has not been delivered on a tangible medium for a minimum of 14 days without stating reasons.
The entrepreneur may ask the consumer for the reason for withdrawal, but not oblige him to state his
4. The reflection period referred to in paragraph 3 commences on the day following the conclusion of the
Extended cooling-off period for products, services and digital content that is not delivered on a material medium if you do not inform about the right of withdrawal:
5. If the entrepreneur has not provided the consumer with the legally required information about the right
of withdrawal or the model withdrawal form, the reflection period will expire twelve months after the
end of the original reflection period determined in accordance with the previous paragraphs of this
6. If the entrepreneur has provided the consumer with the information referred to in the previous
paragraph within twelve months after the commencement date of the original cooling-off period, the
cooling-off period will expire 14 days after the day on which the consumer received that information.
Article 7 – Obligations of the consumer during the cooling-off period
1 .During the reflection period, the consumer will handle the product and the packaging with care. He will
only unpack or use the product to the extent necessary to determine the nature, characteristics and
functioning of the product. The basic principle here is that the consumer may only handle and inspect
the product as he would be allowed to do in a store.
2. The consumer is only liable for depreciation of the product that is the result of a way of handling the
product that goes beyond what is permitted in paragraph 1.
3. The consumer is not liable for depreciation of the product if the entrepreneur has not provided him with
all legally required information about the right of withdrawal before or at the conclusion of the
Article 8 – Exercise of the right of withdrawal by the consumer and costs thereof
1. If the consumer makes use of his right of withdrawal, he will report this to the entrepreneur within the cooling-off period by means of the model withdrawal form or in another unambiguous manner.
2. As soon as possible, but within 14 days from the day following the notification referred to in paragraph 1, the consumer returns the product, or hands it over to (an authorized representative of) the entrepreneur. This is not necessary if the entrepreneur has offered to collect the product himself. The consumer has in any case observed the return period if he returns the product before the reflection period has expired.
3. The consumer returns the product with all accessories supplied, if reasonably possible in its original condition and packaging, and in accordance with the reasonable and clear instructions provided by the entrepreneur.
4. The risk and the burden of proof for the correct and timely exercise of the right of withdrawal rests with the consumer.
5. The consumer bears 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 indicates that he will bear the costs himself, the consumer does not have to bear the costs for return.
6. If the consumer withdraws after having first expressly requested that the provision of the service or the supply of gas, water or electricity that has not been made ready for sale in a limited volume or certain quantity starts during the cooling-off period, the consumer owes the entrepreneur an amount that is proportional to that part of the obligation that has been fulfilled by the entrepreneur at the time of withdrawal, compared to the full fulfillment of the obligation.
7. The consumer shall not bear any costs for the performance of services or the supply of water, gas or electricity that have 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 legally required information about the right of withdrawal, the reimbursement of costs in the event of withdrawal or the model form for withdrawal, or;b. the consumer has not expressly requested the commencement of the performance of the service or the delivery of gas, water, electricity or district heating during the reflection period.
8. The consumer shall not bear any costs for the full or partial delivery of digital content not supplied
on a tangible medium, if:
a. prior to the delivery thereof, he has not expressly agreed to commence fulfillment of the agreement before the end of the cooling-off period;
b. he has not acknowledged to lose his right of withdrawal when granting his consent; or
c. the entrepreneur has failed to confirm this statement from the consumer.
9. If the consumer makes use of his right of withdrawal, all additional agreements will be dissolved by
operation of law.
Article 9 – Obligations of the entrepreneur in the event of withdrawal
1. If the entrepreneur makes the notification of withdrawal by the consumer possible electronically, he will immediately send a confirmation of receipt after receiving this notification.
2. The entrepreneur reimburses all payments from the consumer, including any delivery costs charged by the entrepreneur for the returned product, of which the entrepreneur can determine that this product is in the packaging of the return, immediately but within 14 days following on the day on which the consumer notifies him of the withdrawal. Unless the entrepreneur offers to collect the product himself, he may wait with repayment until he has received the product or until the consumer demonstrates that he has returned the product, whichever is earlier.
3. The entrepreneur uses the same payment method that the consumer has used for reimbursement, unless the consumer agrees to a different method. The refund is free of charge for the consumer.
4. If the consumer has opted for a more expensive method of delivery than the cheapest standard delivery, the entrepreneur does not have to reimburse the additional costs for the more expensive method.
Article 10 – Exclusion right of withdrawal
The entrepreneur can exclude the following products and services from the right of withdrawal, but only if the entrepreneur has clearly stated this in the offer, at least in time for the conclusion of the agreement:
1. Products or services whose price is subject to fluctuations in the financial market over which the entrepreneur has no influence and which may occur within the withdrawal period
2. Agreements concluded during a public auction. A public auction is understood to mean a sales method in which products, digital content and/or services are offered by the entrepreneur to the consumer who is personally present or who is given the opportunity to be personally present at the auction, under the direction of an auctioneer, and where the successful bidder is obliged to purchase the products, digital content and/or services;
3. Service agreements, after full performance of the service, but only if:a. the execution has started with the express prior consent of the consumer; andb. the consumer has declared that he will lose his right of withdrawal as soon as the entrepreneur has fully performed the agreement;
4. Service agreements for the provision of accommodation, if a specific date or period of performance is provided for in the agreement and other than for residential purposes, freight transport, car rental services and catering;
5. Agreements relating to leisure activities, if the agreement provides for a specific date or period for its implementation;
6. Products manufactured to consumer specifications, which are not prefabricated and which are manufactured on the basis of an individual choice or decision of the consumer, or which are clearly intended for a specific person;
7. Products that spoil quickly or have a limited shelf life;
8. Sealed products that are not suitable for health protection or hygiene reasons
9. Products that are irrevocably mixed with other products after delivery by their nature;
10. Alcoholic drinks, the price of which has been agreed upon at the conclusion of the agreement, but the delivery of which can only take place after 30 days, and the actual value of which depends on fluctuations in the market over which the entrepreneur has no influence;
11. Sealed audio, video recordings and computer software, the seal of which has been broken after delivery;
12. Newspapers, periodicals or magazines, with the exception of subscriptions thereto;
13. The supply of digital content other than on a tangible medium, but only if:a. the execution has started with the express prior consent of the consumer; andb. the consumer has declared that he loses his right of withdrawal.
Article 11 – The price
1. During the period of validity stated in the offer, the prices of the products and/or services offered will not be increased, except for price changes as a result of changes in VAT rates.
2. Contrary to the previous paragraph, the entrepreneur can offer variable prices for products or services whose prices are subject to fluctuations in the financial market and over which the entrepreneur has no influence. This dependence on fluctuations and the fact that any prices mentioned are target prices are stated in the offer.
3. Price increases within 3 months after the conclusion of the agreement are only permitted if they are the result of statutory regulations or provisions.
4. Price increases from 3 months after the conclusion of the agreement are only permitted if the entrepreneur has stipulated this and:a. they are the result of statutory regulations or provisions; orb. the consumer has the authority to cancel the agreement with effect from the day on which the price increase takes effect.
5. The prices stated in the offer of products or services include VAT.
Article 12 – Compliance with the agreement and extra guarantee
1. The entrepreneur guarantees that the products and/or services comply with the agreement, the specifications stated in the offer, the reasonable requirements of reliability and/or usability and the statutory provisions existing on the date of the conclusion of the agreement. regulations and/or government regulations. If agreed, the entrepreneur also guarantees that the product is suitable for other than normal use.
2. An extra guarantee provided by the entrepreneur, his supplier, manufacturer or importer never limits the legal rights and claims that the consumer can assert against the entrepreneur under the agreement if the entrepreneur has failed to comply with his part of the agreement.
3. An extra guarantee is understood to mean any commitment by the entrepreneur, his supplier, importer or producer in which he grants the consumer certain rights or claims that go beyond what is legally required in the event that he has failed to fulfill his part of the obligations. the agreement.
Article 13 – Delivery and execution
1. The entrepreneur will take the greatest possible care when receiving and executing orders for products and when assessing applications for the provision of services.
2. The place of delivery is the address that the consumer has made known to the entrepreneur.
3. With due observance of what is stated in article 4 of these general terms and conditions, the entrepreneur will execute accepted orders expeditiously but at the latest within 30 days, unless a different delivery period has been agreed. If the delivery is delayed, or if an order cannot or only partially be executed, the consumer will be notified of this no later than 30 days after he has placed the order. In that case, the consumer has the right to dissolve the agreement without costs and is entitled to any compensation.
4. After dissolution in accordance with the previous paragraph, the entrepreneur will immediately refund the amount that the consumer has paid.5. The risk of damage and/or loss of products rests with the entrepreneur until the moment of delivery to the consumer or a representative designated in advance and made known to the entrepreneur, unless expressly agreed otherwise.
Article 14 – Duration transactions: duration, cancellation and extension
1. The consumer may cancel at any time an agreement that has been entered into for an indefinite period and which extends to the regular delivery of products (including electricity) or services,with due observance of the agreed cancellation rules and a notice period of no more than one month.
2. The consumer can terminate an agreement that has been entered into for a definite period and which extends to the regular delivery of products (including electricity) or services, at any time towards the end of the fixed term, with due observance of the agreed cancellation rules and a notice period. of a maximum of one month.
3. The consumer can conclude the agreements referred to in the previous paragraphs:- cancel at any time and are not limited to cancellation at a specific time or in a specific period;- at least cancel in the same way as they entered into by him;- always cancel with the same notice period as the entrepreneur has stipulated for himself.
4. An agreement that has been entered into for a definite period of time and which extends to the regular delivery of products (including electricity) or services may not be tacitly extended or renewed for a definite period.
5. Contrary to the previous paragraph, a contract that has been entered into for a definite period and which extends to the regular delivery of daily news and weekly newspapers and magazines may be tacitly extended for a fixed term of a maximum of three months, if the consumer has extended this can terminate the agreement towards the end of the extension with a notice period of at most one month.
6. An agreement that has been entered into for a definite period and which extends to the regular delivery of products or services may only be tacitly extended for an indefinite period if the consumer is allowed to cancel at any time with a notice period of no more than one month. The notice period is a maximum of three months if the agreement extends to the regular, but less than once a month, delivery of daily, news and weekly newspapers and magazines.
7. An agreement with a limited duration for the regular delivery of daily, news and weekly newspapers and magazines (trial or introductory subscription) is not tacitly continued and ends automatically after the trial or introductory period.
8. If an agreement has a duration of more than one year, the consumer may terminate the agreement at any time after one year with a notice period of no more than one month, unless reasonableness and fairness oppose cancellation before the end of the agreed duration.
Article 15 – Payment
1. Insofar as not provided otherwise in the agreement or additional conditions, the amounts owed by the consumer must be paid within 14 days after the start of the cooling-off period, or in the absence of a cooling-off period within 14 days after the conclusion of the cooling-off period. agreement. In the case of an agreement to provide a service, this period starts on the day after the consumer has received confirmation of the agreement.
2. When selling products to consumers, the consumer may never be obliged in general terms and conditions to pay more than 50% in advance. When advance payment is stipulated, the consumer cannot assert any rights with regard to the execution of the relevant order or service(s) before the stipulated advance payment has been made.
3. The consumer has the obligation to immediately report inaccuracies in the payment details provided or stated to the entrepreneur.
4. If the consumer does not fulfill his payment obligation(s) in time, after he has been informed by the entrepreneur of the late payment and the entrepreneur has granted the consumer a period of 14 days to still meet his payment obligations, after failure to pay within this 14-day period, the statutory interest will be owed on the amount still owed and the entrepreneur is entitled to charge the extrajudicial collection costs incurred by him. These collection costs amount to a maximum of: 15% on outstanding amounts up to € 2,500; 10% on the next € 2,500 and 5% on the next € 5,000 with a minimum of € 40, =. The entrepreneur can deviate from the stated amounts and percentages in favor of the consumer.
Article 16 – Complaints procedure
1. The entrepreneur has a sufficiently publicized complaints procedure and handles the complaint in accordance with this complaints procedure.
2. Complaints about the execution of the agreement must be submitted fully and clearly described to the entrepreneur within a reasonable time after the consumer has discovered the defects.
3. Complaints submitted to the entrepreneur will be answered within a period of 14 days from the date of receipt. If a complaint requires a foreseeable longer processing time, the entrepreneur will answer within the period of 14 days with a notification of receipt and an indication when the consumer can expect a more detailed answer.
4. A complaint about a product, service or the service of the entrepreneur can also be submitted via a complaint form on the consumer page of the website of Stichting Webshop Keurmerk
(http://keurmerk.info/Home/MisbruikOfKlacht). The complaint will be sent to the relevant entrepreneur as well as to Stichting Webshop Keurmerk.
5. If the complaint cannot be resolved in mutual consultation within a reasonable period or within 3 months of submitting the complaint, a dispute will arise that is subject to the dispute settlement procedure.
Article 17 – Disputes
1. Agreements between the entrepreneur and the consumer to which these general terms and conditions apply are exclusively governed by Dutch law.
2. Disputes between the consumer and the entrepreneur about the conclusion or implementation of agreements with regard to products and services to be delivered or delivered by this entrepreneur can, with due observance of the provisions below, be submitted by both the consumer and the entrepreneur to the Disputes Committee Webshop, PO Box 90600, 2509 LP, The Hague (www.sgc.nl)
3. A dispute will only be dealt with by the Disputes Committee if the consumer has first submitted his complaint to the entrepreneur within a reasonable time.
4. No later than twelve months after the dispute has arisen, the dispute must be submitted in writing to the Disputes Committee.
5. If the consumer wishes to submit a dispute to the Disputes Committee, the entrepreneur is bound by this choice. If the entrepreneur wishes to do so, the consumer will have to state in writing within five weeks after a written request to that effect by the entrepreneur whether he also wishes to do so or whether he wants the dispute to be handled by the competent court. If the entrepreneur is not informed of the consumer's choice within the period of five weeks, the entrepreneur is entitled to submit the dispute to the competent court.
6. The Disputes Committee makes a decision under the conditions as laid down in the regulations of the Disputes Committee (http://www.degeschillencommissie.nl/over-ons/de-commissies/2701/webshop) The decisions of the Disputes Committee are made by way of binding advice.
7. The Disputes Committee will not deal with a dispute or will discontinue the handling if the entrepreneur has been granted a suspension of payments, has gone bankrupt or has actually terminated his business activities, before a dispute has been dealt with by the committee at the hearing and a final verdict has been given.
8. If, in addition to the Webshop Disputes Committee, another disputes committee recognized or affiliated with the Stichting Geschillencommissies voor Consumentenzaken (SGC) or the Financial Services Complaints Institute (Kifid) is competent, the Disputes Committee Stichting Webshop is responsible for disputes mainly concerning the method of selling or providing services at a distance. Approval of approval is preferred. For all other disputes, the other recognized disputes committee affiliated with SGC or Kifid.
Article 18 – Industry guarantee
1. Stichting Webshop Keurmerk guarantees compliance with the binding advice of the Disputes Committee Stichting Webshop Keurmerk by its members, unless the member decides to submit the binding advice to the court for review within two months after it has been sent. This guarantee is revived if the binding advice has remained in force after review by the court and the judgment from which this appears has become final. Up to a maximum amount of €10,000 per binding advice, this amount will be paid to the consumer by Stichting Webshop Keurmerk. For amounts greater than €10,000 per binding advice, €10,000 will be paid out. For the excess, Stichting Webshop Keurmerk has a best efforts obligation to ensure that the member complies with the binding advice.
2. The application of this guarantee requires that the consumer makes a written appeal to Stichting Webshop Keurmerk and that he transfers his claim against the entrepreneur to Stichting Webshop Keurmerk.
3. Webshop Hallmark. If the claim against the entrepreneur exceeds €10,000, the consumer is offered to transfer his claim, insofar as it exceeds the amount of €10,000, to Stichting Webshop Keurmerk, after which this organization will make the payment in its own name and costs. will demand it in court to satisfy the consumer.
Article 19 – Additional or different provisions
1. Additional provisions or provisions that deviate from these general terms and conditions may not be to the detriment of the consumer and must be recorded in writing or in such a way that they can be stored by the consumer in an accessible manner on a durable data carrier.
2. In the event that the translation of these general terms and conditions interprets the intention differently, the Dutch version filed with the Chamber of Commerce shall prevail.
Article 20 – Amendment of the general terms and conditions of Stichting Webshop Keurmerk
1. Stichting Webshop Keurmerk will not change these general terms and conditions except in consultation with the Consumers' Association.
2. Changes to these terms and conditions will only take effect after they have been published in an appropriate manner, on the understanding that in the event of any applicable changes during the term of an offer, the provision most favorable to the consumer will prevail.
Address Stichting Webshop Keurmerk: Weteringschans 108 1017 XS Amsterdam, The Netherlands
Annex I: Withdrawal form