ANNEX — MODEL WITHDRAWAL FORM

(Please complete and return this form only if you wish to withdraw from the contract.)

To:

Ammar Osei-Mohamend

8 bis rue Abel, 75012 Paris

Email: contact@molleva.fr

I/We (*) hereby give notice of my/our (*) withdrawal from the contract for the sale of the service below:

Service concerned: Molleva Premium subscription — Monthly / Annual plan (*)

Ordered on (*) / received on (*): ___________________________

Name of consumer(s): ___________________________

Address of consumer(s): ___________________________

Email used for the Molleva account: ___________________________

Signature of consumer(s): ___________________________

(only if this form is submitted on paper)

Date: ___________________________

(*) Delete as appropriate.