CERTIFICATE ON THE HONOR OF NOT RECEIVING PACKAGES

DISCLAIMER OF SIGNATURE

Dispatch date of the parcel: │__│__│__│__│__│__│

RECIPIENT PACKED

Name :

Surname :

Delivery adress :

Phone number :

Email :

I, the undersigned ………………….……………. testify on the honor not to have received the parcel n°…………….… announced delivered on the date of (delivery date of the follow-up) corresponding to the order (number) passed on the web site(Name of the web site).

Similarly, I certify that I did not sign this delivery slip, it is not my signature, but a forgery.

I have read the provisions of the article of law 441-7 of the French penal code, repressing the establishment of a statement of fact materially inaccurate, hereafter:

“ Is punished by one year imprisonment and a fine of 15 000 euros for establishing a certificate or certificate stating facts that are materially inaccurate”.

I have been informed that the information provided on the occasion of this solemn declaration is the subject of a computer processing necessary for the examination of my request.

They may give rise, in accordance with the provisions of the French law "Computing and Freedom» of January 6, 1978 as amended in 2004, the exercise of the right of access, rectification and, where appropriate, cancellation

Signature :	Date :