CANCELLATION FORM

To, Webloyalty International SARL, at 23 route de Crassier (Business Park Terre Bonne, Bâtiment A3), 1262 Eysins, Switzerland or [email protected] I hereby give notice that I cancel my contract for the supply of the following service, Shopper Discounts & Rewards

Ordered on, _______________________________________________ Name: _________________________________________ Address: _________ Signature: _________ (only if this form is notified on paper) Date _________________________________________