Cancellation Form

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

To Hibiki Systems Ltd.

- 27 Old Gloucester Street, London, United Kingdom, WC1N 3AX

- support@hibikisystems.com

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