1. (a)

   concerning the creditor

If applicable

Representative of the creditor in your Member State of residence

[Identity]

Address

Telephone number18

E-mail address18

Fax number18

Web address18

[Geographical address to be used by the consumer]

If applicable

Registration

[The trade register in which the creditor is entered and his registration number or an equivalent means of identification in that register]

If applicable

The supervisory authority

1. (b)

   concerning the credit agreement

Right of withdrawal

Yes/no

You have the right to withdraw from the credit agreement within a period of 14 calendar days.

If applicable

Exercise of the right of withdrawal

[Practical instructions for exercising the right of withdrawal indicating, inter alia, the address to which notification of exercise of the right of withdrawal should be sent and the consequences of non-exercise of that right]

If applicable

The law taken by the creditor as a basis for the establishment of relations with you before the conclusion of the credit contract

If applicable

Clause stipulating the law applicable to the credit agreement and/or the competent court

[Relevant clause to be set out here]

If applicable

Language regime

Information and contractual terms will be supplied in [specific language]. With your consent, we intend to communicate in [specific language/languages] during the duration of the credit agreement.

1. (c)

   concerning redress

Existence of and access to out-of-court complaint and redress mechanism

[Whether or not there is an out-of-court complaint and redress mechanism for the consumer who is party to the distance contract and, if so, the methods of access to it]