Privacy&Terms

PRIVACY POLICY

 

This privacy policy applies between you, the User of this Website and LONGEVITY ORGANICS LTD, the owner and
provider of this Website. LONGEVITY ORGANICS LTD takes the privacy of your information very seriously. This
privacy policy applies to our use of any and all Data collected by us or provided by you in relation to your use of the
Website.
This privacy policy should be read alongside, and in addition to, our Terms and Conditions, which can be found at: https://www.longevityorganics.co.uk/terms-conditions
Please read this privacy policy carefully

 

Definitions and interpretation

 

1. In this privacy policy, the following definitions are used:

Data
collectively all information that you submit to LONGEVITY ORGANICS LTD via the Website. This definition incorporates, where applicable, the definitions provided in the Data Protection Laws;
Data Protection Laws
any applicable law relating to the processing of personal Data, including but not limited to the Directive 96/46/EC (Data Protection Directive) or the GDPR, and any national implementing laws, regulations and secondary legislation, for as long as the GDPR is effective in the UK; GDPR the General Data Protection Regulation (EU) 2016/679;
LONGEVITY ORGANICS LTD, we or us
LONGEVITY ORGANICS LTD, a company incorporated in England and Wales with registered number 12262482 whose registered office is at 71-75 Shelton Street, Covent Garden, London, England, WC2H 9JQ;
User or you
any third party that accesses the Website and is not either (i) employed by LONGEVITY ORGANICS LTD and acting in the course of their employment or (ii) engaged as a consultant or otherwise providing services to LONGEVITY ORGANICS LTD and accessing the Website in connection with the provision of such services; and
Website
the website that you are currently using, www.longevityorganics.co.uk, and any sub-domains of this site unless expressly excluded by their own terms and conditions.

 

2. In this privacy policy, unless the context requires a different interpretation:

a. the singular includes the plural and vice versa;
b. references to sub-clauses, clauses, schedules or appendices are to sub-clauses, clauses, schedules or appendices of
this privacy policy;
c. a reference to a person includes firms, companies, government entities, trusts and partnerships;
d. “including” is understood to mean “including without limitation”;
e. reference to any statutory provision includes any modification or amendment of it;
f. the headings and sub-headings do not form part of this privacy policy.

Scope of this privacy policy

 

3. This privacy policy applies only to the actions of LONGEVITY ORGANICS LTD and Users with respect to this
Website. It does not extend to any websites that can be accessed from this Website including, but not limited to, any
links we may provide to social media websites.

4. For purposes of the applicable Data Protection Laws, LONGEVITY ORGANICS LTD is the “data controller”. This
means that LONGEVITY ORGANICS LTD determines the purposes for which, and the manner in which, your Data is
processed.

Data collected

 

5. We may collect the following Data, which includes personal Data, from you:

a. name;
b. date of birth;
c. gender;
d. job title;
e. contact Information such as email addresses and telephone numbers;
f. IP address (automatically collected);
g. phone number;
in each case, in accordance with this privacy policy.

How we collect Data

6. We collect Data in the following ways:
a. data is given to us by you ; and
b. data is collected automatically.

Data that is given to us by you

7. LONGEVITY ORGANICS LTD will collect your Data in a number of ways, for example:
a. when you contact us through the Website, by telephone, post, e-mail or through any other means;
b. when you register with us and set up an account to receive our products/services;
c. when you complete surveys that we use for research purposes (although you are not obliged to respond to them);
d. when you enter a competition or promotion through a social media channel;
e. when you make payments to us, through this Website or otherwise;
f. when you elect to receive marketing communications from us;
g. when you use our services;
in each case, in accordance with this privacy policy.

Data that is collected automatically

8. To the extent that you access the Website, we will collect your Data automatically, for example:
awe automatically collect some information about your visit to the Website. This information helps us to make
improvements to Website content and navigation, and includes your IP address, the date, times and frequency with
which you access the Website and the way you use and interact with its content.

Our use of Data

9. Any or all of the above Data may be required by us from time to time in order to provide you with the best possible service and experience when using our Website. Specifically, Data may be used by us for the following reasons:
a. internal record keeping;
b. improvement of our products / services;
c. transmission by email of marketing materials that may be of interest to you;
d. contact for market research purposes which may be done using email, telephone, fax or mail. Such information
may be used to customise or update the Website;
e. Promoting other products and businesses;
in each case, in accordance with this privacy policy.

10. We may use your Data for the above purposes if we deem it necessary to do so for our legitimate interests. If you are
not satisfied with this, you have the right to object in certain circumstances (see the section headed “Your rights”
below).

11. For the delivery of direct marketing to you via e-mail, we’ll need your consent, whether via an opt-in or soft-opt-in:
a.soft opt-in consent is a specific type of consent which applies when you have previously engaged with us (for
example, you contact us to ask us for more details about a particular product/service, and we are marketing similar
products/services). Under “soft opt-in” consent, we will take your consent as given unless you opt-out.
b. for other types of e-marketing, we are required to obtain your explicit consent; that is, you need to take positive
and affirmative action when consenting by, for example, checking a tick box that we’ll provide.
c. if you are not satisfied about our approach to marketing, you have the right to withdraw consent at any time. To
find out how to withdraw your consent, see the section headed “Your rights” below.

12. When you register with us and set up an account to receive our services, the legal basis for this processing is the
performance of a contract between you and us and/or taking steps, at your request, to enter into such a contract.

Who we share Data with

13. We may share your Data with the following groups of people for the following reasons:
a. any of our group companies or affiliates – to ensure the proper administration of your website and business;
b. our employees, agents and/or professional advisors – to obtain advice from professional advisers & gain
knowledge on customers ;
c. third party service providers who provide services to us which require the processing of personal data – to help
third party service providers in receipt of any shared data to perform functions on our behalf to help ensure the
website runs smoothly and also help customers know about any other business or products ;
d. third party payment providers who process payments made over the Website – to enable third party payment
providers to process user payments and refunds;
in each case, in accordance with this privacy policy.

Keeping Data secure

14. We will use technical and organisational measures to safeguard your Data, for example:
a. access to your account is controlled by a password and a user name that is unique to you.
b. we store your Data on secure servers.

15. Technical and organisational measures include measures to deal with any suspected data breach. If you suspect any
misuse or loss or unauthorised access to your Data, please let us know immediately by contacting us via this e-mail
address: info@longevityorganics.co.uk.

16. If you want detailed information from Get Safe Online on how to protect your information and your computers and
devices against fraud, identity theft, viruses and many other online problems, please visit www.getsafeonline.org. Get
Safe Online is supported by HM Government and leading businesses.
Data retention

17. Unless a longer retention period is required or permitted by law, we will only hold your Data on our systems for the
period necessary to fulfil the purposes outlined in this privacy policy or until you request that the Data be deleted.

18. Even if we delete your Data, it may persist on backup or archival media for legal, tax or regulatory purposes.

Your rights

19. You have the following rights in relation to your Data:
a. Right to access – the right to request (i) copies of the information we hold about you at any time, or (ii) that we
modify, update or delete such information. If we provide you with access to the information we hold about you,
we will not charge you for this, unless your request is “manifestly unfounded or excessive.” Where we are legally
permitted to do so, we may refuse your request. If we refuse your request, we will tell you the reasons why.
b. Right to correct – the right to have your Data rectified if it is inaccurate or incomplete.
c. Right to erase – the right to request that we delete or remove your Data from our systems.
d. Right to restrict our use of your Data – the right to “block” us from using your Data or limit the way in which
we can use it.
e. Right to data portability – the right to request that we move, copy or transfer your Data.
f. Right to object – the right to object to our use of your Data including where we use it for our legitimate interests.

20. To make enquiries, exercise any of your rights set out above, or withdraw your consent to the processing of your Data
(where consent is our legal basis for processing your Data), please contact us via this e-mail address:
info@longevityorganics.co.uk.

21. If you are not satisfied with the way a complaint you make in relation to your Data is handled by us, you may be able
to refer your complaint to the relevant data protection authority. For the UK, this is the Information Commissioner’s
Office (ICO). The ICO’s contact details can be found on their website at https://ico.org.uk/.

22. It is important that the Data we hold about you is accurate and current. Please keep us informed if your Data changes
during the period for which we hold it.

Links to other websites

23. This Website may, from time to time, provide links to other websites. We have no control over such websites and are
not responsible for the content of these websites. This privacy policy does not extend to your use of such websites. You
are advised to read the privacy policy or statement of other websites prior to using them.
Changes of business ownership and control

24. LONGEVITY ORGANICS LTD may, from time to time, expand or reduce our business and this may involve the sale
and/or the transfer of control of all or part of LONGEVITY ORGANICS LTD. Data provided by Users will, where it is
relevant to any part of our business so transferred, be transferred along with that part and the new owner or newly
controlling party will, under the terms of this privacy policy, be permitted to use the Data for the purposes for which it
was originally supplied to us.

25. We may also disclose Data to a prospective purchaser of our business or any part of it.

26. In the above instances, we will take steps with the aim of ensuring your privacy is protected.
General

27. You may not transfer any of your rights under this privacy policy to any other person. We may transfer our rights
under this privacy policy where we reasonably believe your rights will not be affected.

28. If any court or competent authority finds that any provision of this privacy policy (or part of any provision) is invalid,
illegal or unenforceable, that provision or part-provision will, to the extent required, be deemed to be deleted, and the
validity and enforceability of the other provisions of this privacy policy will not be affected.

29. Unless otherwise agreed, no delay, act or omission by a party in exercising any right or remedy will be deemed a
waiver of that, or any other, right or remedy.

30. This Agreement will be governed by and interpreted according to the law of England and Wales. All disputes arising
under the Agreement will be subject to the exclusive jurisdiction of the English and Welsh courts.

Changes to this privacy policy

31. LONGEVITY ORGANICS LTD reserves the right to change this privacy policy as we may deem necessary from time
to time or as may be required by law. Any changes will be immediately posted on the Website and you are deemed to
have accepted the terms of the privacy policy on your first use of the Website following the alterations.
You may contact LONGEVITY ORGANICS LTD by email at info@longevityorganics.co.uk.

Attribution

32. This privacy policy was created using a document from Rocket Lawyer (https://www.rocketlawyer.com/gb/en).
  

TERMS AND CONDITIONS

  

Please read all these terms and conditions.

As we can accept your order and make a legally enforceable agreement without further reference to you, you must read
these terms and conditions to make sure that they contain all that you want and nothing that you are not happy with.

Application

1. These Terms and Conditions will apply to the purchase of the goods by you (the Customer or you). We are
LONGEVITY ORGANICS LTD whose trading name is LONGEVITY ORGANICS a company registered in England
and Wales under number 11210664 whose registered office is at 71-75 Shelton Street, Covent Garden, London,
London, WC2H 9JQ and whose trading address is Unit 20, Booth House, Featherstall Road, OL9 7TQ with email
address info@longevityorganics.co.uk; (the Supplier or us or we).

2. These are the terms on which we sell all Goods to you. By ordering any of the Goods, you agree to be bound by these
Terms and Conditions. Before placing an order on the Website, you will be asked to agree to these Terms and
Conditions by clicking on the button marked ‘I Accept’. If you do not click on the button, you will not be able to
complete your Order. You can only purchase the Goods from the Website if you are eligible to enter into a contract
and are at least 18 years old.

Interpretation

3. Consumer means an individual acting for purposes which are wholly or mainly outside his or her trade, business, craft
or profession;

4. Contract means the legally-binding agreement between you and us for the supply of the Goods;

5. Delivery Location means the Supplier’s premises or other location where the Goods are to be supplied, as set out in
the Order;

6. Durable Medium means paper or email, or any other medium that allows information to be addressed personally to
the recipient, enables the recipient to store the information in a way accessible for future reference for a period that is
long enough for the purposes of the information, and allows the unchanged reproduction of the information stored;

7. Goods means the goods advertised on the Website that we supply to you of the number and description as set out in
the Order;

8. Order means the Customer’s order for the Goods from the Supplier as submitted following the step by step process set
out on the Website;

9. Privacy Policy means the terms which set out how we will deal with confidential and personal information received
from you via the Website;

10. Website means our website www.longevityorganics.co.uk on which the Goods are advertised.

Goods

11. The description of the Goods is as set out in the Website, catalogues, brochures or other form of advertisement. Any
description is for illustrative purposes only and there may be small discrepancies in the size and colour of the Goods
supplied.

12. In the case of any Goods made to your special requirements, it is your responsibility to ensure that any information or
specification you provide is accurate.

13. All Goods which appear on the Website are subject to availability.

14. We can make changes to the Goods which are necessary to comply with any applicable law or safety requirement. We
will notify you of these changes.

Personal information and Registration

15. When registering to use the Website you must set up a username and password. You remain responsible for all actions
taken under the chosen username and password and undertake not to disclose your username and password to anyone
else and keep them secret.

16. We retain and use all information strictly under the Privacy Policy.

17. We may contact you by using e-mail or other electronic communication methods and by pre-paid post and you
expressly agree to this.

Basis of Sale

18. The description of the Goods in our website does not constitute a contractual offer to sell the Goods. When an Order
has been submitted on the Website, we can reject it for any reason, although we will try to tell you the reason without
delay.

19. The Order process is set out on the Website. Each step allows you to check and amend any errors before submitting
the Order. It is your responsibility to check that you have used the ordering process correctly.

20. A Contract will be formed for the sale of Goods ordered only when you receive an email from us confirming the Order
(Order Confirmation). You must ensure that the Order Confirmation is complete and accurate and inform us
immediately of any errors. We are not responsible for any inaccuracies in the Order placed by you. By placing an Order
you agree to us giving you confirmation of the Contract by means of an email with all information in it (ie the Order
Confirmation). You will receive the Order Confirmation within a reasonable time after making the Contract, but in any
event not later than the delivery of any Goods supplied under the Contract.

21. Any quotation is valid for a maximum period of 14 days from its date, unless we expressly withdraw it at an earlier
time.

22. No variation of the Contract, whether about description of the Goods, Fees or otherwise, can be made after it has been
entered into unless the variation is agreed by the Customer and the Supplier in writing.

23. We intend that these Terms and Conditions apply only to a Contract entered into by you as a Consumer. If this is not
the case, you must tell us, so that we can provide you with a different contract with terms which are more appropriate
for you and which might, in some respects, be better for you, eg by giving you rights as a business.
Price and Payment

24. The price of the Goods and any additional delivery or other charges is that set out on the Website at the date of the
Order or such other price as we may agree in writing.

25. Prices and charges include VAT at the rate applicable at the time of the Order.

26. You must pay by submitting your credit or debit card details with your Order and we can take payment immediately or
otherwise before delivery of the Goods.

Delivery

27. We will deliver the Goods, to the Delivery Location by the time or within the agreed period or, failing any agreement,
without undue delay and, in any event, not more than 30 days after the day on which the Contract is entered into.

28. In any case, regardless of events beyond our control, if we do not deliver the Goods on time, you can (in addition to
any other remedies) treat the Contract at an end if:
a. we have refused to deliver the Goods, or if delivery on time is essential taking into account all the relevant
circumstances at the time the Contract was made, or you said to us before the Contract was made that delivery on
time was essential; or
b. after we have failed to deliver on time, you have specified a later period which is appropriate to the circumstances
and we have not delivered within that period.

29. If you treat the Contract at an end, we will (in addition to other remedies) promptly return all payments made under the
Contract.

30. If you were entitled to treat the Contract at an end, but do not do so, you are not prevented from cancelling the Order
for any Goods or rejecting Goods that have been delivered and, if you do this, we will (in addition to other remedies)
without delay return all payments made under the Contract for any such cancelled or rejected Goods. If the Goods have
been delivered, you must return them to us or allow us to collect them from you and we will pay the costs of this.

31. If any Goods form a commercial unit (a unit is a commercial unit if division of the unit would materially impair the
value of the goods or the character of the unit) you cannot cancel or reject the Order for some of those Goods without
also cancelling or rejecting the Order for the rest of them.

32. We do not generally deliver to addresses outside England and Wales, Scotland, Northern Ireland, the Isle of Man and
Channels Islands. If, however, we accept an Order for delivery outside that area, you may need to pay import duties or
other taxes, as we will not pay them.

33. You agree we may deliver the Goods in instalments if we suffer a shortage of stock or other genuine and fair reason,
subject to the above provisions and provided you are not liable for extra charges.

34. If you or your nominee fail, through no fault of ours, to take delivery of the Goods at the Delivery Location, we may
charge the reasonable costs of storing and redelivering them.

35. The Goods will become your responsibility from the completion of delivery or Customer collection. You must, if
reasonably practicable, examine the Goods before accepting them.

Risk and Title

36. Risk of damage to, or loss of, any Goods will pass to you when the Goods are delivered to you.

37. You do not own the Goods until we have received payment in full. If full payment is overdue or a step occurs towards
your bankruptcy, we can choose, by notice to cancel any delivery and end any right to use the Goods still owned by
you, in which case you must return them or allow us to collect them.

Withdrawal, returns and cancellation

38. You can withdraw the Order by telling us before the Contract is made, if you simply wish to change your mind and
without giving us a reason, and without incurring any liability.

39. This is a distance contract (as defined below) which has the cancellation rights (Cancellation Rights) set out below.
These Cancellation Rights, however, do not apply, to a contract for the following goods (with no others) in the
following circumstances:
a .foodstuffs, beverages or other goods intended for current consumption in the household and which are supplied on
frequent and regular rounds to your residence or workplace;
b. goods that are made to your specifications or are clearly personalised;
c. goods which are liable to deteriorate or expire rapidly.

40. Also, the Cancellation Rights for a Contract cease to be available in the following circumstances:
a. in the case of a contract for the supply of sealed goods which are not suitable for return due to health protection or
hygiene reasons, if they become unsealed after delivery;
b. in the case of any sales contract, if the goods become mixed inseparably (according to their nature) with other
items after delivery.

Right to cancel

41. Subject as stated in these Terms and Conditions, you can cancel this contract within 14 days without giving any reason.

42. The cancellation period will expire after 14 days from the day on which you acquire, or a third party, other than the
carrier indicated by you, acquires physical possession of the last of the Goods. In a contract for the supply of goods
over time (ie subscriptions), the right to cancel will be 14 days after the first delivery.

43. To exercise the right to cancel, you must inform us of your decision to cancel this Contract by a clear statement setting
out your decision (eg a letter sent by post, fax or email). You can use the attached model cancellation form, but it is not
obligatory. In any event, you must be able to show clear evidence of when the cancellation was made, so you may
decide to use the model cancellation form.

44. You can also electronically fill in and submit the model cancellation form or any other clear statement of the
Customer’s decision to cancel the Contract on our website www.longevityorganics.co.uk. If you use this option, we will
communicate to you an acknowledgement of receipt of such a cancellation in a Durable Medium (eg by email) without
delay.

45. To meet the cancellation deadline, it is sufficient for you to send your communication concerning your exercise of the
right to cancel before the cancellation period has expired.
Effects of cancellation in the cancellation period

46. Except as set out below, if you cancel this Contract, we will reimburse to you all payments received from you,
including the costs of delivery (except for the supplementary costs arising if you chose a type of delivery other than the
least expensive type of standard delivery offered by us).

Deduction for Goods supplied

47. We may make a deduction from the reimbursement for loss in value of any Goods supplied, if the loss is the result of
unnecessary handling by you (ie handling the Goods beyond what is necessary to establish the nature, characteristics
and functioning of the Goods: eg it goes beyond the sort of handling that might be reasonably allowed in a shop). This
is because you are liable for that loss and, if that deduction is not made, you must pay us the amount of that loss.

Timing of reimbursement

48. If we have not offered to collect the Goods, we will make the reimbursement without undue delay, and not later than:
a. 14 days after the day we receive back from you any Goods supplied, or
b. (if earlier) 14 days after the day you provide evidence that you have sent back the Goods.

49. If we have offered to collect the Goods or if no Goods were supplied, we will make the reimbursement without undue
delay, and not later than 14 days after the day on which we are informed about your decision to cancel this Contract.

50. We will make the reimbursement using the same means of payment as you used for the initial transaction, unless you
have expressly agreed otherwise; in any event, you will not incur any fees as a result of the reimbursement.

Returning Goods

51. If you have received Goods in connection with the Contract which you have cancelled, you must send back the Goods
or hand them over to us at 71-75 Shelton Street, Covent Garden, London, London, WC2H 9JQ without delay
and in any event not later than 14 days from the day on which you communicate to us your cancellation of this
Contract. The deadline is met if you send back the Goods before the period of 14 days has expired. You agree that you
will have to bear the cost of returning the Goods.

52. For the purposes of these Cancellation Rights, these words have the following meanings:
a. distance contract means a contract concluded between a trader and a consumer under an organised distance sales
or service-provision scheme without the simultaneous physical presence of the trader and the consumer, with the
exclusive use of one or more means of distance communication up to and including the time at which the contract
is concluded;
b. sales contract means a contract under which a trader transfers or agrees to transfer the ownership of goods to a
consumer and the consumer pays or agrees to pay the price, including any contract that has both goods and
services as its object.

Conformity

53. We have a legal duty to supply the Goods in conformity with the Contract, and will not have conformed if it does not
meet the following obligation.

54. Upon delivery, the Goods will:
a. be of satisfactory quality;
b. be reasonably fit for any particular purpose for which you buy the Goods which, before the Contract is made, you
made known to us (unless you do not actually rely, or it is unreasonable for you to rely, on our skill and judgment)
and be fit for any purpose held out by us or set out in the Contract; and
c. conform to their description.

55. It is not a failure to conform if the failure has its origin in your materials.

56. We will provide the following after-sales service: The supplier will be available through email or social media from
9AM – 5PM to take any questions or queries on the products.

Successors and our sub-contractors

57. Either party can transfer the benefit of this Contract to someone else, and will remain liable to the other for its
obligations under the Contract. The Supplier will be liable for the acts of any sub-contractors who it chooses to help
perform its duties.

Circumstances beyond the control of either party

58. In the event of any failure by a party because of something beyond its reasonable control:
the party will advise the other party as soon as reasonably practicable; and
the party’s obligations will be suspended so far as is reasonable, provided that that party will act reasonably, and
the party will not be liable for any failure which it could not reasonably avoid, but this will not affect the
Customer’s above rights relating to delivery and any right to cancel, below.

Privacy

59. Your privacy is critical to us. We respect your privacy and comply with the General Data Protection Regulation with
regard to your personal information.

60. These Terms and Conditions should be read alongside, and are in addition to our policies, including our privacy policy
() and cookies policy ().

61. For the purposes of these Terms and Conditions:
a. ‘Data Protection Laws’ means any applicable law relating to the processing of Personal Data, including, but not
limited to the Directive 95/46/EC (Data Protection Directive) or the GDPR.
‘GDPR’ means the General Data Protection Regulation (EU) 2016/679.
‘Data Controller’, ‘Personal Data’ and ‘Processing’ shall have the same meaning as in the GDPR.

62. We are a Data Controller of the Personal Data we Process in providing Goods to you.

63. Where you supply Personal Data to us so we can provide Goods to you, and we Process that Personal Data in the
course of providing the Goods to you, we will comply with our obligations imposed by the Data Protection Laws:
a. before or at the time of collecting Personal Data, we will identify the purposes for which information is being
collected;
b. we will only Process Personal Data for the purposes identified;
c. we will respect your rights in relation to your Personal Data; and
d. we will implement technical and organisational measures to ensure your Personal Data is secure.

64. For any enquiries or complaints regarding data privacy, you can e-mail: info@longevityorganics.co.uk.

Excluding liability

65. The Supplier does not exclude liability for: (i) any fraudulent act or omission; or (ii) for death or personal injury
caused by negligence or breach of the Supplier’s other legal obligations. Subject to this, the Supplier is not liable for (i)
loss which was not reasonably foreseeable to both parties at the time when the Contract was made, or (ii) loss (eg loss
of profit) to the Customer’s business, trade, craft or profession which would not be suffered by a Consumer – because
the Supplier believes the Customer is not buying the Goods wholly or mainly for its business, trade, craft or profession.
Governing law, jurisdiction and complaints

66. The Contract (including any non-contractual matters) is governed by the law of England and Wales.

67. Disputes can be submitted to the jurisdiction of the courts of England and Wales or, where the Customer lives in
Scotland or Northern Ireland, in the courts of respectively Scotland or Northern Ireland.

68. We try to avoid any dispute, so we deal with complaints in the following way: If a dispute occurs customers should
contact us by email to find a solution. We will aim to respond with an appropriate solution within 5 days..
Attribution

69. These terms and conditions were created using a document from Rocket Lawyer (https://www.rocketlawyer.com/gb
/en).
Model cancellation Form
To
LONGEVITY ORGANICS LTD
71-75 Shelton Street, Covent Garden, London
London
WC2H 9JQ

Email address: info@longevityorganics.co.uk

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 [*], Ordered on [*]/received on [*]______________________(date received)
Name of consumer(s):
Address of consumer(s):
Signature of consumer(s) (only if this form is notified on paper)
Date
[*] Delete as appropriate.