CANCELLATION FORM

 

Please complete and return this form if you wish to cancel any of your OmegaBrite AutoRefill automatic recurring order programs. Please send the form to

Omega Natural Science, Inc.
8275 S Eastern Avenue
Suite 121
Las Vegas, NV 89123
USA

Or fax it to (781) 652-0504

I hereby give notice that I withdraw from my contract for the provision of my OmegaBrite AutoRefill automatic recurring order program.

Ordered on:

Your name:

Your address:

Your email address:

 

Date:

Your signature: