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Mediarun.com Terms of Service

Rules for using the Service: the account, content and comments, the company directory and rankings, the AI assistant, tokens, the shop, complaints and withdrawal from contracts.

This English version is an AI-assisted translation provided for information only. The Polish version is legally binding.

Version of
7 October 2026
In force from
7 October 2026
Company
HEXAGON NETWORK INT LTDCompanies House, No. 16085570 · 85 Uxbridge Road, London W5 5TH, United Kingdom

For contracts for paid services concluded before 7 October 2026, the new version applies from 21 October 2026; until that date, the version of 8 September 2026 applies.

§ 1General provisions

  1. These Terms of Service (the “Terms”) set out the rules for using the Mediarun.com website (the “Service”), including the rules for the provision of services by electronic means.
  2. The Service is operated by HEX-NET spółka z ograniczoną odpowiedzialnością, with its registered office in Warsaw, ul. Franciszka Klimczaka 1 (Royal Wilanów), 02-797 Warszawa, Poland, entered in the register of entrepreneurs of the National Court Register (Krajowy Rejestr Sądowy, KRS) maintained by the Sąd Rejonowy dla m.st. Warszawy w Warszawie, XIII Wydział Gospodarczy Krajowego Rejestru Sądowego (District Court for the Capital City of Warsaw in Warsaw, 13th Commercial Division of the National Court Register), under KRS number 0001191786, tax identification number (NIP) 9512628812, statistical number (REGON) 542599939, with share capital of PLN 10,000.00 (the “Publisher”). Contact details of the Publisher: [email protected], tel. +48 505 460 020.
  3. Products offered in the Shop are sold by HEXAGON NETWORK INT LTD, a company registered in England and Wales (Companies House) under company number 16085570, with its registered office at 85 Uxbridge Road, London W5 5TH, United Kingdom (the “Seller”). For matters concerning orders, you may write to [email protected] or call +48 505 460 020.
  4. The Service provides, in particular: editorial content (news, articles, case studies, interviews), a directory of companies, brands, media and people in the marketing industry, rankings, a glossary, calculators, tests and quizzes, job offers, an Account with the AI Assistant, and the Shop with Products.
  5. Browsing the content of the Service is free of charge and does not require an Account. Only Products ordered in the Shop are subject to payment.
  6. Use of the Service requires a device with internet access and an up-to-date web browser with JavaScript, cookies and browser storage enabled, such as Chrome, Edge, Firefox or Safari in a version released within the last two years. An active e-mail address is required to create an Account, subscribe to the newsletter and make purchases. A voice conversation with the AI Assistant requires a microphone and the browser’s permission to use it.
  7. The use of services provided by electronic means involves the risks typical of the internet, including malware, phishing and password theft. The Publisher encrypts the connection to the Service (HTTPS) and never asks for a password by e-mail or by telephone. We recommend keeping software up to date, using a strong and unique password, and logging out on shared devices.
  8. The User is prohibited from providing content of an unlawful nature.
  9. The Terms are available free of charge at mediarun.com/pl/regulamin (English translation: mediarun.com/en/terms) in a form that allows them to be downloaded, printed and saved.

§ 2Definitions

User
any person using the Service.
Account
a free reader account in the Service with a panel (profile, Tokens, tasks, conversations with the AI Assistant, briefs, calendar).
Consumer
a natural person who concludes a contract that is not directly related to their business or professional activity.
Sole Trader with Consumer Rights
a natural person who concludes a contract directly related to their business activity, where the content of the contract shows that the contract is not of a professional nature for that person, as follows in particular from the subject of their business activity disclosed in CEIDG (the Polish Central Register and Information on Economic Activity).
Business
a natural person, a legal person or an organisational unit that concludes a contract in connection with its business or professional activity, other than a Sole Trader with Consumer Rights.
Shop
the part of the Service at mediarun.com/en/shop (Polish version: /pl/sklep) and the HEXX tools shop, in which Products may be ordered.
Products
paid services and other offerings available in the Shop, in particular Mediarun HUB subscriptions, HEXX tool subscriptions and analyses, competition entries, event tickets, partnership packages, job advertisements, sponsored publications and advertising.
Buyer
a person who places an order in the Shop.
Company Profile
the page of a company, brand, agency, media outlet, organisation, supplier or creator in the directory of the Service.
Company Panel
the part of the Account in which a verified person manages a Company Profile.
Authorised Person
a member of the management board, a partner or shareholder (wspólnik), an owner (an entrepreneur entered in CEIDG) or a commercial proxy (prokurent) of the company, as well as an attorney acting under a written power of attorney granted by one of those persons.
Ranking
a compilation of companies, brands, media or people prepared by the editorial team of the Service, including one published under the name “Mediarun Ranking”.
AI Assistant
the assistant of the Service (Jasmin, formerly MR Advisor), based on artificial intelligence language models and available in a window on the pages of the Service and in the Account.
Tokens
units in the Account wallet that are used to access selected features of the Service (§ 11).
User Content
comments, messages, descriptions, photographs, logos, Company Profile data and other materials provided by a User or a company.

§ 3Account

  1. Creating and maintaining an Account is free of charge. To create an Account, the User must provide an e-mail address, accept the Terms and read the Privacy Policy. This also applies to an Account created in a conversation with the AI Assistant: the AI Assistant may prepare the details, but the User checks them and accepts the Terms and gives any consents personally.
  2. The contract for maintaining an Account is concluded for an indefinite period at the moment the Account is created.
  3. Some features — in particular the award of welcome Tokens and rewards — require the e-mail address to be confirmed using the link in a message sent by the Service.
  4. The User provides true information, keeps their password confidential and is responsible for actions performed using their Account. Each person may hold only one Account.
  5. The User may terminate the contract and delete the Account at any time by writing to [email protected] from the e-mail address assigned to the Account. Deleting the Account results in the loss of Tokens and conversation history; order and invoice data are retained for as long as required by law.
  6. The Publisher may block or delete an Account if the User continues to breach the Terms after being asked to stop, and without such a request in the event of a gross breach: publication of unlawful content, spam, impersonation of another person, attempts to gain unauthorised access to the Service or to other users’ Accounts, or abuse of the Token programme. The Publisher informs the User of the reasons for its decision and of the possibility of appeal (§ 5).

§ 4User Content and comments

  1. A User who posts User Content represents that they hold the rights to it and that it does not infringe the law, personal rights (dobra osobiste) or the rights of third parties, including copyright, trade marks and trade secrets.
  2. It is prohibited to post content:
    1. that is unlawful or offensive, or that incites hatred or violence;
    2. that is promotional without the Publisher’s consent, including affiliate links and spam;
    3. that contains personal data of third parties without a legal basis;
    4. that misleads as to the identity of the author or impersonates another person or company;
    5. that contains malware or leads to it.
  3. Comments are published after approval by a moderator, with the name given in the Account.
  4. The User grants the Publisher a free-of-charge, non-exclusive licence, unlimited in territory, to use User Content to the extent necessary to operate the Service: recording and reproduction on servers, and making it available to the public in the Service, in the newsletter and in the Service’s social media channels, with the right to shorten it and with the author credited. The licence lasts for the period of publication and, in archives and backup copies, until they are deleted in the ordinary cycle.
  5. A company that provides a logo, photographs or descriptions for its Company Profile grants the Publisher the same licence to display them in the Company Profile, in Rankings, in listings and in editorial materials about the company.

§ 5Reporting illegal content and moderation

  1. The Publisher stores and publishes User Content — in particular comments, Company Profile data and descriptions, and messages to companies and authors — in accordance with Regulation (EU) 2022/2065 on a Single Market for Digital Services (Digital Services Act, “DSA”).
  2. Content may be reviewed by the Publisher’s team before and after publication. The Publisher may refuse publication, restrict visibility, remove content or suspend an Account if the content infringes the law or the Terms.
  3. Anyone may report content they consider to be illegal by writing to [email protected]. The notice should contain: an explanation of why the content is illegal; the exact web address of the content; the name and e-mail address of the person submitting the notice (not required for notices concerning content related to the sexual abuse of children); and a statement that the person submitting the notice believes in good faith that the information contained in it is accurate and complete.
  4. The Publisher confirms receipt of the notice, handles it without undue delay and informs the person who submitted it of its decision. The author of content that has been removed or restricted receives a statement of reasons for the decision together with information about the possibility of appeal. An appeal may be submitted to the same address within 6 months and is considered by a person other than the one who made the decision. This is without prejudice to the right to bring the matter before a court.
  5. The point of contact for the authorities of the Member States, the European Commission and the European Board for Digital Services, and for recipients of the service, is [email protected]. Communication is possible in Polish and in English.

§ 6Editorial content, copyright and databases

  1. The editorial content, the layout of the Service, designations and logos, the company directory, the Rankings and other databases of the Service are protected by copyright and database rights.
  2. They may be used within the limits of permitted use under copyright law, in particular by quoting excerpts with an indication of the source and a link to the Service.
  3. The following are prohibited without the Publisher’s consent: republishing all or a substantial part of any material; systematic extraction (including by automated tools) and re-utilisation of a substantial part of the company directory, the Rankings and other databases of the Service; circumventing the technical safeguards of the Service.
  4. Sponsored publications and partner materials are labelled as partner content or advertising. The sender of press releases and submitted materials is responsible for their content.
  5. The Service contains links to third-party websites. The Publisher is not responsible for their content or for the rules on data processing applied on those websites.

§ 7Company directory, Company Profiles and their removal

  1. Company Profiles are prepared by the Publisher on the basis of publicly available sources — in particular the National Court Register (KRS), CEIDG, the register of VAT taxpayers, the VIES system, company websites (including those retrieved automatically), press releases and publications of the Service — and of materials provided by companies.
  2. A Company Profile is for information purposes and shows data as at the date on which they were retrieved. The Publisher exercises due care but does not guarantee the completeness or currency of data originating from registers and third-party websites.
  3. Anyone may report an error in a Company Profile. The Publisher corrects data found to be untrue or out of date without undue delay.
  4. A company may take over the management of its Company Profile in the Company Panel. Access is granted to a person whose authority the Publisher confirms automatically (an e-mail address in the company’s domain belonging to a person entered in the register, or an order paid with the company’s NIP tax number) or after verification by a moderator.

Removal or hiding of a Company Profile at the company’s request

  1. A company may request the amendment, hiding or removal of its Company Profile using the “Request a change or removal of the profile” form (linked from the page of every Company Profile; form in the Account) or by writing to [email protected]. A request may be submitted only by an Authorised Person: a member of the management board, a partner or shareholder, an owner, a commercial proxy or an attorney.
  2. Before removal, the Publisher verifies that the request has been submitted by an Authorised Person. Any one of the following methods is sufficient:
    1. the applicant’s first name and surname match the entry in the KRS or CEIDG, and the e-mail address is in the company’s domain;
    2. a statement or power of attorney signed by a person entered in the register with a qualified electronic signature or a Polish trusted signature (podpis zaufany);
    3. confirmation by the company via the telephone number or e-mail address given in the register or on its official website.
  3. The Publisher does not request scans of identity documents. If the authority cannot be confirmed, the Publisher informs the applicant accordingly and indicates what is missing.
  4. The Publisher handles a complete request within 14 days. Following successful verification, the Company Profile is hidden in the Service and is not automatically recreated from public sources.
  5. The removal of a Company Profile does not extend to: articles and other editorial materials, results of competitions and Rankings published before the request was submitted, information about award winners, or data from public registers cited in publications. The Publisher may refuse removal where this is justified by a legitimate public interest in access to information, and gives reasons for any refusal.
  6. Natural persons whose data appear in Company Profiles may exercise the rights described in the Privacy Policy, including the right to object and the right to erasure of data.

§ 8Rankings

  1. Rankings are prepared by the editorial team of the Service in accordance with the methodology described for each Ranking, in particular on the basis of financial data from financial statements filed with the KRS, results of industry competitions and awards, and other publicly available information.
  2. A Ranking is an editorial opinion based on data available on the date of publication. It is not a recommendation, an offer or a quality certificate, and a position in a Ranking does not guarantee a company’s results.
  3. A position in a Ranking cannot be bought. The purchase of Products does not affect the order or the assessment. Completing the data in a Company Profile may be a condition for including a company in a Ranking if the methodology requires data that are not available from public sources.
  4. The Publisher does not verify the accuracy of data from financial statements and public registers. A company may report an error in the data; once the error is confirmed, the editorial team corrects the Ranking.
  5. A company may publicise its position by stating the name and year of the Ranking and providing a link to the Service. Use of the “Mediarun Ranking” designation and Ranking graphics in advertising requires the Publisher’s consent.

§ 9AI Assistant and content created with the help of AI

  1. The AI Assistant is an assistant based on artificial intelligence — its answers are generated by a language model, not by a human. They may be incomplete, out of date or incorrect and do not constitute legal, tax, financial or investment advice.
  2. Conversations with the AI Assistant are recorded — including when the User is not logged in — so that the AI Assistant can continue the conversation and tailor its answers. After the User logs in, the conversation is transferred to the Account. The rules and retention period for conversations are described in the Privacy Policy. Sensitive data and data of third parties should not be provided in a conversation.
  3. The AI Assistant may remember information provided by the User in a conversation (e.g. job title, company, interests) in order to tailor content and answers. The User may at any time request that such information be rectified or deleted.
  4. The User uses content generated in HEXX tools and by the AI Assistant (texts, graphics, recordings, music, documents) at their own risk. Before publishing or using such content, the User should check it for accuracy, lawfulness and compliance with third-party rights. The Publisher and the Seller do not guarantee that generated content is unique or that it is protected by copyright. Licensing restrictions applicable to individual tools (e.g. music for non-commercial use only) are stated on the Product page.
  5. The Publisher uses AI tools to prepare some materials, in particular translations and summaries. AI-generated materials that have not been reviewed by the editorial team before publication are labelled as such.

§ 10Newsletter and messages

  1. The newsletter is free of charge and is sent only with the recipient’s consent. Consent may be withdrawn at any time using the link in every message or in the Account settings.
  2. Messages sent using the contact form on a Company Profile are delivered to that company, and messages sent using “Message the author” are delivered to the author and the editorial team. The person replying is responsible for the content of the reply.

§ 11Tokens, tasks and referrals

  1. A logged-in User with a confirmed e-mail address receives Tokens in the Account wallet: a monthly allocation and rewards for tasks (e.g. completing the profile, a quiz), for referrals and for other activities described in the Service. The current rules and numbers of Tokens are set out in the Account, on the “Tokens and referrals” page.
  2. Tokens may be used solely to access features of the Service on the terms described in the Service. They are not electronic money or a means of payment, cannot be exchanged for money or other benefits, and cannot be transferred to another Account or sold.
  3. Tokens have an expiry date shown in the wallet history; unused Tokens expire on that date. Deleting the Account results in the loss of Tokens.
  4. A referral reward is granted when the invited person creates an Account using the referral link and confirms their e-mail address. No rewards are granted for referring oneself or for Accounts created for the purpose of obtaining rewards. The detailed conditions of the programme (e.g. the requirement of a business e-mail address, the monthly limit of rewards) are set out in the Account.
  5. The Publisher may revoke Tokens granted as a result of abuse — e.g. creating multiple Accounts or automating actions — and may change the rules of the programme with effect for the future. A change does not take away Tokens granted before it takes effect.

§ 12Shop and Products

  1. The description, scope, limits, duration and price of a Product are stated on its Product page and in the cart before the order is placed.
  2. The Shop sells exclusively to Businesses and Sole Traders with Consumer Rights — when ordering, the Buyer provides the company name and tax identification number (Polish NIP or EU VAT number). Consumers may not place orders in the Shop.
  3. The contract is concluded with the Seller. It is concluded at the moment payment is confirmed or a bank transfer made on the basis of a pro forma invoice is credited. The Seller sends the order confirmation and the invoice to the e-mail address given in the order.
  4. The price shown in the cart is the final price payable by the Buyer. Information on VAT is provided on the Product page and in the cart. Prices are given in Polish zloty (Polish version) or in euro (English version); the price in each currency is set separately. The invoice is issued in the currency of the order.
  5. Payments are handled by the payment operator Revolut: Visa or Mastercard card payments in the operator’s form (card details do not reach the Seller’s servers), Revolut Pay, Google Pay, Apple Pay or a bank transfer on the basis of a pro forma invoice. The availability of payment methods depends on the Buyer’s country.
  6. A subscription is paid in advance for the chosen period (one month or one year), ends when that period expires and does not renew automatically. During the period, it is possible to switch to a different plan; the difference is settled pro rata.
  7. Free forms of use — the Free plan, the first use of a tool or a trial period — have the scope described on the offer page. They do not require payment details, end automatically and do not turn into a paid subscription without an order.
  8. Tickets and competition entries relate to the event specified on the Product page (date, venue, scope). Participation in the event and in the competition is governed by their respective rules, available at dyrektormarketinguroku.pl and executivesummit.eu. An additional ticket for a competition participant may be purchased only together with an entry.
  9. Sponsored publications and advertisements are labelled in the Service as partner content or advertising. The Buyer supplies the materials within the time limit agreed when the order is placed. The Publisher may refuse to publish material that is contrary to the law, to good practice (dobre obyczaje) or to the character of the Service; in that case the Seller refunds the fee in full.
  10. Job advertisements are published for the period stated on the Product page. The advertiser is responsible for the content of the advertisement, including its compliance with the prohibition of discrimination in employment. Candidates apply directly to the employer.
  11. The Publisher and the Seller provide their services with due care but do not guarantee that any particular position will be achieved in search engines or in the answers of AI models — results depend on factors beyond their control.

Additional benefits in plans paid annually in advance

  1. Where the Product description provides for additional benefits when payment is made annually in advance — in particular event tickets, a competition entry, participation of the Buyer’s representative in a panel discussion or a discount on additional tickets — paragraphs 13–16 apply to them.
  2. Additional benefits:
    1. relate to the next edition of the event or competition within the subscription period, unless the Product description provides otherwise;
    2. are personal — the Buyer may designate another person from its company by notifying the Seller before the event;
    3. cannot be exchanged for a cash equivalent and, if not used within the relevant period, expire;
    4. are transferred to the next edition of the event if the event is cancelled.
  3. Panel participation: the topic, line-up and format of the panel are determined by the event organiser. The panellist may be a person holding a managerial position with the Buyer. Contributions may not be promotional in nature. The organiser may, for good reason, change the line-up of the panel, offering participation in another panel or another form of appearance. The panellist gives separate consent to the recording and publication of their image.
  4. The discount on additional tickets is available for as long as a subscription paid annually in advance remains active, is calculated on the ticket price applicable on the date of purchase and cannot be combined with discount codes, unless the Product description provides otherwise.
  5. If the Buyer withdraws from the contract or the contract expires before the end of the annual period, the value of the additional benefits used is settled according to the prices shown on the Product page on the date of the order.

§ 13Liability

  1. The content of the Service is for information purposes and does not constitute legal, tax, financial or investment advice. The Publisher makes every effort to ensure that it is reliable but is not liable for decisions taken solely on the basis of that content.
  2. The Publisher is not liable for interruptions in the operation of the Service resulting from technical causes, force majeure or the actions of third parties. The Publisher gives advance notice of planned interruptions.
  3. The Publisher is not liable for User Content or for content provided by companies unless, having received credible information about its unlawful nature, it fails to disable access to it promptly.
  4. In relations with Businesses:
    1. the Publisher and the Seller are liable only for actual loss (damnum emergens) — liability for loss of profits (lucrum cessans) is excluded;
    2. total liability in connection with a Product is limited to the amount of the fees paid for that Product in the 12 months preceding the event giving rise to the claim;
    3. rights under the statutory warranty for defects (rękojmia), where applicable, are excluded;
    4. the above limitations do not apply to damage caused intentionally.
  5. A Buyer who is a Business and provides materials for publication (logos, photographs, texts, sponsored materials, advertisements) warrants that it holds the rights to them. If a third party brings a claim on account of those materials, the Buyer shall indemnify the Publisher and the Seller against liability and shall cover reasonable costs, including the costs of legal representation.
  6. The limitations in paragraphs 4 and 5 do not apply to Consumers or Sole Traders with Consumer Rights, towards whom the Publisher and the Seller are liable in accordance with the general provisions of law.

§ 14Complaints

  1. A complaint concerning the Service or a Product may be submitted by e-mail to [email protected] or in writing to the address of the Publisher or the Seller. Please include a description of the problem, the date on which it occurred, the Account e-mail address or the order number, and the resolution you expect.
  2. The Publisher or the Seller responds to a complaint within 14 days of its receipt. If it does not respond to a Consumer’s complaint within that period, the complaint is deemed to have been accepted.
  3. Liability towards a Consumer and a Sole Trader with Consumer Rights for the conformity of a digital service with the contract is governed by Chapter 5b of the ustawa z dnia 30 maja 2014 r. o prawach konsumenta (Polish Consumer Rights Act of 30 May 2014).

§ 15Withdrawal from the contract

  1. A Consumer and a Sole Trader with Consumer Rights may withdraw from a contract concluded in the Shop within 14 days of the date of its conclusion, without giving any reason. It is sufficient to send a statement to [email protected] or by post to the Seller’s address before that period expires. The model withdrawal form may be used, but this is not obligatory. The Seller acknowledges receipt of the statement without delay.
  2. If the Consumer requested that performance begin before the end of the withdrawal period and then withdraws from the contract, the Consumer pays for the performance rendered up to the moment of withdrawal, in proportion to its scope.
  3. The Buyer indicates at checkout, before placing the order, the request for performance to begin before the end of the withdrawal period and the acknowledgement that the right of withdrawal will be lost once the service has been fully performed; the Seller confirms both in the order confirmation message.
  4. The right of withdrawal does not apply in the cases specified in Article 38 of the ustawa o prawach konsumenta (Consumer Rights Act), in particular:
    1. where the Seller has fully performed the service with the express prior consent of the Consumer, who was informed before performance began that they would lose the right of withdrawal once the service had been performed, and acknowledged this;
    2. in the case of contracts for the provision of services related to entertainment, sporting or cultural events, where the contract specifies the day or period of performance of the service;
    3. in the case of the supply of digital content not supplied on a tangible medium, where performance began with the express consent of the Consumer before the end of the withdrawal period, after the Consumer had been informed of the loss of that right.
  5. The Seller refunds the payment without undue delay and in any event no later than 14 days after receiving the statement of withdrawal, using the same means of payment as the Consumer used, unless the Consumer agrees to a different method of refund that involves no costs for the Consumer.
  6. A Business does not have the right to withdraw from a contract concluded in the Shop.

§ 16Personal data

The rules for processing personal data, including profiling and cookies, are described in the Privacy Policy. The accessibility of the Service is described in the Accessibility Statement.

§ 17Force majeure

The Publisher and the Seller are not liable for non-performance or improper performance of obligations caused by force majeure — an external event that could not have been foreseen or prevented, in particular a natural disaster, an epidemic, acts of war, decisions of public authorities, or a failure of the power or telecommunications network beyond their control. If an event is cancelled due to force majeure, the organiser endeavours to move it to another date; the rules for refunds are set out in the rules of the event.

§ 18Amendments to the Terms, governing law and disputes

  1. The Publisher may amend the Terms for valid reasons: a change in the law, a change in the scope or manner of providing services, a change in the security measures of the Service, or in order to remove ambiguities. The Publisher announces amendments in the Service and notifies Account holders and Buyers with active Products by e-mail 14 days in advance. A User who does not accept the amendments may delete their Account before they take effect. Paid Products in progress remain subject to the existing rules until the end of the paid period, unless the amendment results from the law.
  2. These Terms are governed by Polish law. This choice of law does not deprive a Consumer of the protection afforded by the mandatory provisions of the law of the country of their habitual residence.
  3. Disputes with Consumers are resolved by the courts having jurisdiction under the general provisions of law. Disputes with Businesses are resolved by the common courts having jurisdiction for the Capital City of Warsaw.
  4. A Consumer may use out-of-court methods of handling complaints and pursuing claims: refer the matter to a permanent consumer arbitration court, apply to the provincial inspector of the Trade Inspection (Inspekcja Handlowa) for mediation proceedings to be initiated, or obtain free assistance from a district (municipal) consumer ombudsman. Information on these methods is available on the website of the Urząd Ochrony Konkurencji i Konsumentów (Polish Office of Competition and Consumer Protection): uokik.gov.pl.
  5. These Terms are in force from 7 October 2026. The previous version was in force from 8 September 2026.

Annex 1Model withdrawal form

Complete and return this form only if you wish to withdraw from the contract.

Withdrawal form

To: HEXAGON NETWORK INT LTD, 85 Uxbridge Road, London W5 5TH, United Kingdom, e-mail: [email protected]

I/We(*) hereby give notice that I/we(*) withdraw from my/our(*) contract for the provision of the following service(*) / for the supply of the following digital service(*): …………………………………

Date of conclusion of the contract: …………………………………

Name of consumer(s): …………………………………

Address of consumer(s): …………………………………

Signature of consumer(s) (only if this form is sent on paper): …………………………………

Date: …………………………………

(*) Delete as appropriate.

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