Terms of Service (TOS)

Last updated: June 2021

Applicability of these Terms

These Terms govern your use (in the broadest sense of the word) of our Website and Services. These Terms are an integral part of a legally binding agreement between you and Longevize.

By using our Website and Services, you acknowledge to have read, understood, and agree to be bound by, these Terms.

Who are we?

This Website and the Services are offered to you by, and any agreements concluded in this regard will be concluded with, Longevize B.V. (“Longevize,” “we,” or “us” or “our”) is an AI-driven, integrated personalized longevity platform that helps individuals like you (“User” or “you” or “your”) understand how ageing processes work and empowers them to own their unique biology and optimize their lifestyle choices.

Our registered (and visiting) address is J.H. Oortweg 21 (2333 CH) in Leiden, the Netherlands.

You can contact us via e-mail at info@longevize.com. Our customer service is available on business days between 9am and 5pm (CET).

Our VAT identification number is NL861513691B01.

Definitions / Terminology

For the purpose of these Terms, the following terms shall have a special meaning:

  • Direct Damages: all costs, losses or damages, whatever the legal basis thereof (i.e. tort, contract or otherwise), directly attributable to a Party’s material breach of these Terms.
  • Indirect Damages: all costs, losses or damages which do not qualify as Direct Damages. Regardless of its qualification under the previous sentence, Indirect Damages shall always include: indirect damages, punitive damages, consequential damages, loss of profits, loss of data, loss of savings, immaterial damages, and damage due to business interruption or delays.
  • Testing Kits: saliva testing kits, stool testing kits, and other testing kits that must be used by the User (or in certain cases by specialized service providers) in order for us to be able to offer our Services.
  • Longevize: Longevize B.V. or the company registered with the trade registry in the Netherlands (Kamer van Koophandel) as 78739152; also referred to as “we”, “us” or “our”.
  • Order Confirmation: an e-mail confirming receipt of your order.
  • Parties: Longevize and the User, together.
  • Party: either Longevize or the User, depending on the context.
  • Personalized Supplements: the food supplements offered by Longevize that have been tailored on the basis of the results of the testing and analysis via Testing Kits.
  • Samples: saliva samples, stool samples, blood samples, and other biological samples acquired from Users in the context of our Services.
  • Self-reported Health Information: information volunteered by you about your health or lifestyle in response to our questionnaires and which help tailor our Services to your specific needs.
  • Services: the collection of services and offerings offered by Longevize via the Website including, but not limited to the ones described in Clause 4.
  • Subscriptions: the Services ordered by User, for which the User is obliged to pay a recurring monthly fee.
  • Terms: an abbreviation used to refer to these terms of service (i.e. this document you are currently reviewing).
  • Test Data: the raw results of testing and analysis of Samples by the laboratories arranged by Longevize.
  • User: any natural person or legal entity browsing our Website and/or using our Services; also referred to in these Terms as “you” or “your”.
  • Website: the website(s) through which we offer our Services, available at the following URL(s): https://www.longevize.com, and regardless of how you view them (e.g. via mobile app or browser).

Services offered via the Website

Our Services  may include one or more of the following:

  • Biology Testing. We organize the collection, testing and analysis of Samples using Testing Kits and by partnering with our local phlebotomy service providers. The testing and analysis will result in Test Data.
  • Drafting Longevity Report. Test Data may be combined with any Self-Reported Health Information, and we may generate reports using big data and machine learning techniques and algorithms. Through these Longevity Reports we will provide you with longevity-focused insights into your biology.
  • Providing Personalized Supplements. Using the information from the Biology Testing and Longevity Report, we may provide you with recommendations on personalized food supplements tailored to your unique biology which we can conveniently deliver as tailored sachets to your door. Subscription to our Personalized Supplements is not available without Biology Testing services which provide the necessary Test Data and Customer’s Longevity Report. Our Personalized Supplements are not available to minors below age of 18;
  • Longevity Lifestyle Recommendations. Value-added access to longevity focused personalized lifestyle and nutrition recommendations and insights via our Website based on your Test Data;
  • Progress Monitoring. It may include either of the following: (i) biology retesting – blood, telomere, microbiome and/or epigenetics retesting to follow your progress and adjust the Personalized Supplements as necessary; or (ii) personal wellbeing monitoring through self-assessed standardized questionnaires. Progress monitoring service is only available as an add-on service to Subscriptions for Personalized Supplements;
  • Coaching. We offer one-on-one coaching services during which we may offer our interpretation of your Longevity Report, provide you with supplement-related recommendations or help you develop skills that will aid you in reaching your longevity-related objectives.
  • Longevize Longevity App. We may provide you with access to our specialized app which will help you discover scientific information relevant to your longevity-objectives, personalized lifestyle and nutrition recommendations. The Longevize Longevity App will also grant access to the My Longevize Community – a platform for social interactions between likeminded individuals within our community.

Our Services also entail providing you with support during the ordering process, providing you with general instructions on how to use the Testing Kits and Personalized Food Supplements, and providing you with reasonable assistance if the Testing Kits appear to be faulty.

In the performance of our Services, we may procure goods and services from third parties at our own discretion. For example, we do not manufacture the testing kits ourselves. Our supplements are custom manufactured for us in the EU by our quality controlled manufacturing partners. To the extent that blood samples are required, those are collected by qualified phlebotomy providers. Testing and analysis of the saliva, stool and blood samples is performed via accredited laboratories.

How it works?

Users are required to create an account on the Website and are asked to complete an initial questionnaire to start the collection of Self-reported Health Information.

Depending on the specific service Users purchase or subscribe to, Users are asked to collect saliva and stool samples using the Testing Kits provided and return them to Longevize. Collection of blood samples will be arranged by Longevize using partnering phlebotomy service providers instead of a self-administered Testing Kit. Please note that the collection of certain samples (e.g. blood samples) may require a referral by your General Practitioner (huisarts).

All collected Samples will be forwarded for testing and analysis to laboratories arranged by Longevize. Collected samples will be used by the testing laboratories to generate Test Data, and the laboratories will submit such Test Data to Longevize which will analyze them together with any relevant Self-reported Health Information. Longevize will then present synthesized longevity-focused information (so-called ‘Longevity Reports’) back to the User to help User make personalized longevity and lifestyle choices.

Based on User’s Test Data, we will design the Personalized Supplements tailored to the User’s biology which will be conveniently delivered User’s doors each month.

For Users with a Subscription to our Personalized Supplements, Longevize will also provide personalized supplementation guidance, Longevity Lifestyle Recommendations, and access to My Longevize platform. Optionally, Longevize will offer coaching to assist Users in optimizing their longevity-related objectives, as well as access to the Longevize Longevity App which can help Users maintain progress against these objectives.

Users may follow their progress with periodical Biology Retesting on the basis of which their Personalized Supplements and longevity lifestyle recommendations may be adjusted accordingly.

DISCLAIMER OF MEDICAL ADVICE AND TREATMENT

The information and Services provided or made available to you by us and/or via the Website do not constitute medical advice or treatment, nor are they suitable for independently diagnosing, treating, or preventing diseases or health conditions. The information and Services are only meant for educational, recreational and enjoyment purposes and they are not a substitute for medical advice, clinical diagnosis, or treatment by an appropriate qualified medical professional.

We recommend that you only apply the information learned through our Website or only use our Services after seeking medical advice from your General Practitioner (huisarts) or another appropriately qualified medical professional. We encourage you to put forward to them any questions or concerns that you may have. By using our Services you acknowledge that you are aware of the limitations of our Services and the limitations of the information provided via our Website. Moreover, by using our Services, you assume full liability for your reliance on the Services and the information provided to you in the course of that.

Pricing & payment methods

Prices are clearly indicated via the Website in Euros (EUR) or other appropriate local or international currencies and include any value-added tax (VAT) at the corresponding legal rate, where applicable. Our pricing does not include any import taxes and or customs duties. When you order from us, you agree to be responsible for paying any and all such taxes or duties at the time of delivery, as applicable. Although we may change prices from time to time, the total and final price for each order is indicated with your Order Confirmation and price changes do not affect orders for which we have already sent out an Order Confirmation. Changes to the pricing for Subscriptions will not apply to your Subscriptions until 30 days after we have notified you of the change.

You can order Services using the 3rd party payment methods indicated during the ordering process, subject to their availability. We currently offer the following payment methods: Credit Card (accepted brands are listed on the ordering page). Please note that payment methods offered via our Website may require further authorization by third party issuers and scheme owners and this may delay the processing of your order. You agree to ensure that any payment instruments offered up by you are current, owned by you, and that you have sufficient funds available to pay the full value of your order. Any additional charges arising from you not adhering to such requirements will be borne by you.

How we process your orders & why we may refuse or cancel it

To be eligible for ordering Services via our Website, you must:

  • be at least 18 years old, or older if that is required under applicable law to enter into a legally binding agreement with Longevize;
  • lawfully be able to use the Testing Kits, Personalized Supplements, Website and Services under the laws of the country in which you reside;
  • not be pregnant;
  • not have not had a heart attack (myocardial infarction), stroke/transient ischemic attack, or major surgery in the last six months;
  • if you are being treated for chronic medical conditions (including type 1 diabetes or type 2 diabetes), you have checked with your treating physician that this product is safe for you;
  • be a consumer, meaning a natural person who is acting outside their trade, business, craft or profession (i.e. for personal use only);
  • have no intention of reselling or otherwise making available the purchased Services, Personalized Supplements or Testing Kits to third parties; and
  • be located in one of the countries that we offer the Services requested in. This will be made apparent before or during the ordering process.

By placing an order for our Services, you guarantee that you meet the eligibility criteria listed above.

All requests for Services are subject to availability and acceptance of the order by Longevize.

Despite our best efforts, we may not be able to fulfill your order. As such – and in addition to any other rights to refuse or cancel your order – we reserve the right to refuse your order or cancel your order for any of the following reasons:

  • the Services (or part of it) ordered are no longer available;
  • we currently do not have the appropriate Personalized Supplement Product available for you;
  • the pricing was an obvious mistake, and we cannot reasonably be asked to accept such a pricing error;
  • your payment was not received or could otherwise not be properly processed;
  • we reasonably suspect your order to not be in compliance with these Terms;
  • you did not use a Testing Kit in accordance with the instructions provided with it;
  • the address, e-mail-address and/or other information that you provided to us is invalid or we are otherwise unable to deliver Services to you; or
  • we cannot make the Services available to you due to a situation of force majeure (overmacht).

Delays

Despite our best efforts, the processing of your order may be delayed.

For example, the delivery of your Personalized Supplements may be delayed if you fail to provide Samples or Self-Reported Health Information in full or on-time. Sometimes, Longevize may not be able to process a Sample, or our testing process may result in errors due to several reasons which may include Samples containing insufficient volume or the testing results not meeting standards for accuracy (we call these ‘Sample Failures’). This may lead to unexpected delays in processing your Sample. In such cases, we will notify you of the Sample Failure and details applicable to processing a new Sample in place of the failed Sample.

Other reasons for delays may arise from situations of force majeure (incl. severe backlogs, strikes, employee sickness, pandemics, IT-failures, etc.) on our part or on the part of our partners. While we endeavor to take commercially reasonable steps to minimize such delays, we shall not be liable to you or to any third party for any such delays associated with the Services.

Cancellations & Refunds

You are entitled to cancel your order, for whatever reason, in the following scenarios: (a) until you have received the Order Confirmation; or (b) after Order Confirmation, but within 14 calendar days following the day upon which we make Testing Kits available to you. We may ask you to provide a reason for cancellation, but you do not have to tell us.

After the 14 calendar days-term mentioned in Clause 10.1, the following policy applies for cancellation:

  • You will not be refunded for any payments related to the testing fees or for any Personalized Supplements that have already been produced for you;
  • You must have acted in accordance with these Terms, subject to our reasonable discretion;
  • You must pay us a cancellation fee equivalent to (a) the full value of the Subscription’s fees for any cancelled Subscription with a definite term or a full value of the Package fee for any cancelled Package deal; or (b) one month’s worth the cancelled Subscription’s fees for any cancelled Subscription with an indefinite term; and
  • You will retain your access to your User Account but the access to the Services you will keep until the end of the most recently paid month.

Following our acceptance of your cancellation, we will provide you with a written confirmation of cancellation.

Once you have successfully cancelled your order under Clause 10.1 or Clause 10.2,  and returned all unsealed Testing Kits, you will be entitled to a refund and we will reimburse you within 14 calendar days following the day on which we were informed of your decision to invoke your right to cancel your order. All refunds will be paid out to the same payment method used with the original order.

Should you wish to cancel your order, we recommend that you do so using the following means: (a) by completing and submitting the Withdrawal Template Form as indicated in Annex 1; or (b) by contacting us via the means described in Clause 2.3 and by unequivocally stating your decision to cancel your order. In addition, you must return any unused Testing Kits received.

Notwithstanding Clause  10.1 and Clause 10.2, you will never be entitled to a refund: (a) for any Personalized Supplements already produced because they were manufactured specifically for you; (b) for any testing fee if Testing Kits which were sealed for health protection or hygiene purposes have been unsealed by you; (c) for any testing fee if Testing Kits were not used prior to the indicated expiration date; or (d) after you have explicitly asked us to start the performance of Services immediately despite the then still ongoing 14 calendar day cancellation-term.

Cancellation or termination shall never relieve you of, or otherwise affect, any of your accrued payment obligations up until the receipt of the notice of termination, subject to Longevize’s reasonable discretion.

Use of Testing Kits and Personalized Supplements

Testing Kits and Personalized Supplements received from Longevize must only be used for the purposes for which it was advertised and must be used before the expiry dates indicated on each item.

Testing Kits and Personalized Supplements are personal and must only be used by you. You explicitly agree to not share them with or make them available to any third parties other than the ones designated by Longevize.

We retain all title and interest (eigendom) to the Testing Kits and Personalized Supplements supplied to you until you have paid us for the related order in full and compensated us for any damages suffered by us as a result of your breaching these Terms.

Third party services and content

Please be aware that your use of third-party goods and services may be subject to additional terms and conditions (e.g. end-user license agreements or EULA’s, instruction manuals). You warrant that you will comply with all such referenced additional terms and conditions.

Moreover, in order to provide you with a better user experience of the Website, we may require the use of third-party technology components which may be subject to your agreement to terms and conditions supplied by these third parties. We strive to indicate the applicability of such additional terms and conditions where possible in a clear manner and will provide these terms and conditions upon your request.

We may also display, link or provide you with third party content via our Website or Services (e.g. via frames or hyperlinks). That content is the sole responsibility and liability of the third party making it available to you. We have no control over such third-party content. We do not make any warranties, representations, or guarantees with respect to the accuracy, veracity or legal status of such third-party content and disclaim any liability in this regard. We encourage you to read each the terms and conditions and privacy notices provided by such third parties on their own website.

Prohibited use of the Services and Website

When using our Website or Services, you must:

  • use best efforts to protect the confidentiality and security of your User account and login details for the Website;
  • not threaten or harass other Users;
  • not attempt to bypass geographical or other technical restrictions imposed by us on the Service or Website;
  • not remove, obscure, or alter any proprietary rights, marks, or notices that may be affixed to or contained in the Service or Website;
  • not use our Website, Testing Kits, Personalized Supplements, or Services for the processing of infringing or otherwise unlawful content;
  • not infringe upon Longevize’s or a third parties’ intellectual property rights, and not commit any other wrongful acts towards Longevize or any other third party;
  • not use our Website, Testing Kits, Personalized Supplements, or Services for commercial purposes or any other purposes not expressly approved by us, without our prior written consent;
  • not make available our Testing Kits, Personalized Supplements, or Services to third parties except the ones expressly permitted by us;
  • not use automated means to access, copy, or otherwise engage with our Services or Website, beyond using interfaces explicitly provided by us for use by our Users;
  • not interfere with, limit or impede access to or use of the Website or Services for other Users;
  • not acquire access to other Users’ accounts, otherwise acquire access to any parts of our Website or Services of which you are aware or should reasonably be aware that they were not supposed to be available or accessible to you;
  • not adapt, modify or reverse engineer the Website, Testing Kits, Personalized Supplements, or Services, except insofar as such actions cannot be excluded under applicable law, without our explicit prior written consent;
  • not intentionally test the security of our Website or Services, without our explicit prior written consent;
  • not resell or otherwise re-provide (access to) our Website, Services, Testing Kits or Personalized Supplements, without our explicit prior written consent;
  • not tarnish our reputation;
  • comply with all our instructions (and those of our partners) regarding the use of Testing Kits, Personalized Supplements, Services and the Website, including these Terms; and
  • comply with all applicable laws and regulations regarding online conduct, non-discrimination, intellectual property rights and data protection.

Suspension or termination of Services or access to the Website & indemnification

We are entitled to suspend or terminate, with immediate and indefinite effect, and without prior notice, your access to or use of our Website and Services, partly or in full, if you, to be determined at our sole discretion, fail to comply with any of the instructions mentioned in Clause 13.1 or other parts of the Terms. You will not be entitled to any compensation or refund for this.

Notwithstanding Clause 14.1, we will use reasonable efforts to notify you of any decision to suspend or terminate your access to or use of the Website or Services prior to such a decision coming into effect.

If you fail to comply with these Terms and cause damages, our decision to suspend or terminate your access to or use of the Website or Services will not affect our entitlement to also seek compensation for damages and we expressly reserve the right to seek compensation of damages and costs.

You hereby agree to indemnify us and hold us (and our business partners) harmless against any claims for damages arising out of any breach of these Terms attributable to you.

User Generated Content

You may be able to store, upload, submit or otherwise cause content to be processed via our Website or Services (“User Content”). You warrant and represent that (i) you are entitled to provide us (and our partners) with such User Content without infringing any third-party rights, including intellectual property rights and privacy rights; and (ii) the User Content is accurate and not misleading.

You agree to indemnify and hold us and our partners, and our directors and employees, harmless from and against all third-party liabilities, claims, damages and expenses (including reasonable attorney fees) arising from or relating to any User Content stored, uploaded, submitted or otherwise processed via the Services or Website by you.

We are entitled to remove any of your User Content stored, sent or otherwise processed via our Services or Website if necessary to protect our rights or the rights of third parties. We are entitled to do so with immediate effect and without prior notice, but we will try to inform you in advance to give you reasonable time to mitigate the infringement yourself. To the extent permitted by law, we will inform you of any reports we receive from a third party alleging your infringement of their rights.

You hereby grant us a worldwide, perpetual, royalty-free, fully paid, non-exclusive license to use your suggestions, complaints or other User Content for the purpose of correcting, improving or further commercializing our Services and Website. The license contained in this Clause shall survive expiration or termination of any agreement between us. You hereby waive any moral rights (morele rechten) that you may have to such User Content or agree to not enforce them in any way against us.

Changes to the Website and Services

We are entitled to change, modify, revise and/or update the Services and the Website, at any time and at our sole discretion. We aim to do so with minimally adverse impact on your access to or use of the Services and Website and will use best efforts to inform you of any maintenance in advance.

We are entitled to permanently discontinue providing the Services to you or discontinue providing the Website to you, at any time and for whatever reason. We are also entitled to limit the functionality of the Services and Website. We will use best efforts to notify you of such changes in advance.

Changes to the Terms

We reserve the right to make changes to these Terms at any time and without prior notice. Any changes to the Terms shall enter into effect for all Users immediately upon posting the changes to our Website or upon informing you of the changes via other appropriate means. If you do not agree to the changed Terms, you must discontinue your use of the Services and Website immediately and will not be able to submit any further orders.

Data protection and privacy

In order to provide our Website or Services to you, we need to process your personal data. In addition, you yourself may also choose to store, upload, send, submit or otherwise cause content containing your personal data to be processed via our Website or Services.

Longevize is committed to protecting your privacy and security. To find out more about how we do that, please check out our Privacy Policy.

Intellectual property rights

All our intellectual property rights, including but not limited to any copyrights, trademarks, logos, domain names, design rights, database rights and know-how, in connection with the Services, Testing Kits, Personalized Supplements, and the Website, including the selection and arrangement of the user generated content referred to in Clause 15, are and shall remain the sole property of Longevize and, to the extent applicable, its third party licensors.

These Terms do not grant you any license or other right to use our trademarks, logo’s, designs or other intellectual property, nor do we transfer any of our intellectual property to you.

Warranties

We try to provide our Services using a commercially reasonable level of skill and care. However, except as expressly described in these Terms, we exclude to the fullest extent permitted by law all warranties, conditions, or representations with respect to the Testing Kits, Personalized Supplements, the Services and the Website. In particular, we do not make any guarantees or commitments about the reliability, availability, non-infringement or suitability for your needs of our Services and Website. The Services and Website are provided “as is” and “as available”.

Please also be referred to our Medical Advice Disclaimer in Clause 6.

Liability and indemnities

We are not liable for any damages suffered by you, directly or indirectly, related to the use of the Testing Kits, the Personalized Supplements, Website or Services, regardless of the nature of the claim (i.e. tort, contract or otherwise). In particular, you acknowledge and accept that the Services may not yield the information that you had hoped for or may otherwise generate strong emotions.

Should the exclusion of liability as stipulated in Clause 21.1 not be enforceable against you, our liability shall be limited to the compensation of Direct Damages with a maximum of 100% of the fees paid by you for the relevant order(s) placed by you and accepted by us in the last twelve-month period preceding the applicable claim. We are not liable for Indirect Damages.

None of the exclusions or limitations stated in these Terms shall apply to damages caused by intent or deliberate recklessness on our part.

You agree to indemnify and hold Longevize, its partners, and each of their respective directors, employees and agents harmless from and against all third party liabilities, claims, damages, costs and expenses (including reasonable attorney fees) arising from or related to (a) your access to or use of the Testing Kits, Personalized Supplements, Services or Website; (b) your use of customer content, the use of Longevity Reports or Personalized Supplements; and (c) your violation of these Terms.

We are not liable for any delays or failures in performance of any of our obligation towards you, in whole or in part, if such delay or non-performance is due to any cause beyond our (or any of our subcontractors’) reasonable control.

Applicable law and dispute resolution

These Terms are governed by the laws of the Netherlands, without application of its conflict of laws-rules.

Disputes will be exclusively submitted to the competent court in Amsterdam, the Netherlands.

Alternatively and notwithstanding Clause 22.2, you and we may submit any dispute arising in connection to the Website, the Testing Kits, Personalized Supplements, the Services or the Terms to the Online Dispute Resolution (ODR) platform provided by the European Commission (available at  https://ec.europa.eu/consumers/odr).

Miscellaneous

This Terms govern the relationship between you and Longevize, and each agreement that is concluded with you. Together with any specific instructions disclosed to you by Longevize or its partners before, during or after the receipt of your order (e.g., instructions for the use of Testing Kits and/or Personalized Supplements) they contain the entire agreement between the Parties with respect to the subject matter and supersede all prior proposals, agreements, understandings, terms, and contemporaneous discussions, whether oral or written, between the Parties concerning the same subject matter.

These Terms are primarily available in English and all agreements governed by them shall be considered concluded in English. Translations to other languages may be provided for the sake of convenience, but the English original shall always be leading with respect to the interpretation of these Terms and all agreements governed by them.

You may not assign, delegate or transfer these Terms or your rights or obligations hereunder, or your User account, without Longevize’s prior written consent. We are entitled to subcontract and assign our rights and obligations related to our performance of the Services to any third party without your consent.

Should any provision of the Terms be or become invalid or unenforceable in whole or in part, the remaining provisions shall continue to apply in full and the Longevize and User agree to negotiate in good faith with respect to a valid and enforceable provision approaching as closely as possible the intent of the invalid or unenforceable provision, in order to replace it.

All delivery dates and timelines described by Longevize for delivery will be considered non-binding target dates (streeftermijnen), unless expressly agreed upon in writing by Longevize.

Any failure by Longevize to enforce any provision of the Agreement at any time shall not be deemed to be a waiver of its right under these Terms, nor shall it prejudice any of its right to take subsequent action.

Expiry of these Terms, cancellation or other forms of termination of the Terms or the Services will not affect any existing obligations of the User to Longevize, nor will it affect any rights or remedies of the parties that have accrued up until the moment of expiry or termination. In particular, the provisions surrounding liability, and applicable law and dispute resolution shall survive expiry and termination.

All notices, requests, demands and other legally-relevant communications by you to Longevize under these Terms must be in writing and in English language and shall be deemed to have been duly given (i) if sent by registered mail (aangetekende post) to Longevize with available proof of delivery; or (ii) if sent to the Longevize e-mail address listed in Clause 2.3 with available proof of delivery.

Annex 1 – Withdrawal Template Form

TO: LONGEVIZE B.V., J.H. OORTWEG 21 (2333 CH) IN LEIDEN, THE NETHERLANDS (info@longevize.com )

I hereby give notice that I withdraw from my contract of sale concerning the following order: [ description here ].

The order mentioned above was submitted on [ date here ] and made available to me on [ date here ]. My order number (as stated in the Order Confirmation) is [ order number here ].

My name is [ surname and first name here ] and my address is [ address, postal code, city and country of residence here ]. The current date is [ date here ].

Kind regards,

_____________________

[ signature above – if this form is notified on paper ]