JV for EBU (External)

All fields are mandatory except those where "optional" is mentioned.

Your company data

Address for fiber installation

{{errorMessages.lomKey}} The field is mandatory

Primary contact person

Language {{errorMessages.CONTLANG2.required}} {{errorMessages.CONTLANG2.pattern}}

Title {{errorMessages.TITLE2.required}} {{errorMessages.TITLE2.pattern}}

First name {{errorMessages.FNAME2.required}} {{errorMessages.FNAME2.pattern}} {{errorMessages.FNAME2.pattern}} {{errorMessages.FNAME2.pattern}} {{errorMessages.FNAME2}} {{errorMessages.FNAME2.pattern}}

Last name {{errorMessages.LNAME2.required}} {{errorMessages.LNAME2.pattern}} {{errorMessages.LNAME2.pattern}} {{errorMessages.LNAME2.pattern}} {{errorMessages.LNAME2}} {{errorMessages.LNAME2.pattern}}

Prefix {{errorMessages.CONTCB2Country.required}} {{errorMessages.CONTCB2Country}}

Phone number {{errorMessages.CONTCB2Phone.required}} {{errorMessages.CONTCB2Phone.pattern}} {{errorMessages.CONTCB2Phone.pattern}} {{errorMessages.CONTCB2Phone.pattern}} {{errorMessages.CONTCB2Phone}} {{errorMessages.CONTCB2Phone.pattern}}

E-mail {{errorMessages.CONTEMAIL2.required}} {{errorMessages.CONTEMAIL2.pattern}} {{errorMessages.CONTEMAIL2.pattern}} {{errorMessages.CONTEMAIL2.pattern}} {{errorMessages.CONTEMAIL2}} {{errorMessages.CONTEMAIL2.pattern}}

On-site technical contact

Do you want to specify a distinct technical contact? {{errorMessages.isTechnicalContactDifferentThanDecision.required}} {{errorMessages.isTechnicalContactDifferentThanDecision.pattern}}

Language {{errorMessages.CONTLANG.required}} {{errorMessages.CONTLANG.pattern}}

Title {{errorMessages.TITLE.required}} {{errorMessages.TITLE.pattern}}

First name {{errorMessages.FNAME.required}} {{errorMessages.FNAME.pattern}} {{errorMessages.FNAME.pattern}} {{errorMessages.FNAME.pattern}} {{errorMessages.FNAME}} {{errorMessages.FNAME.pattern}}

Last name {{errorMessages.LNAME.required}} {{errorMessages.LNAME.pattern}} {{errorMessages.LNAME.pattern}} {{errorMessages.LNAME.pattern}} {{errorMessages.LNAME}} {{errorMessages.LNAME.pattern}}

Prefix {{errorMessages.CONTCBCountry.required}} {{errorMessages.CONTCBCountry}}

Phone number {{errorMessages.CONTCBPhone.required}} {{errorMessages.CONTCBPhone.pattern}} {{errorMessages.CONTCBPhone.pattern}} {{errorMessages.CONTCBPhone.pattern}} {{errorMessages.CONTCBPhone}} {{errorMessages.CONTCBPhone.pattern}}

E-mail {{errorMessages.CONTEMAIL.required}} {{errorMessages.CONTEMAIL.pattern}} {{errorMessages.CONTEMAIL.pattern}} {{errorMessages.CONTEMAIL.pattern}} {{errorMessages.CONTEMAIL}} {{errorMessages.CONTEMAIL.pattern}}

This information will only be used to make the appointment for the fiber installation.

I agree that my personal data is processed in compliance with the Proximus privacy policy, which provides guidance on how to customize my privacy settings. Your contact details will be shared with Fiberklaar the network builder. For more information, please consult the Fiberklaar privacy policy. You can cancel your connection request at any time, free of charge, through our customer service 0800 55 200. Submitting this request does not obligate you to subscribe to any Proximus fiber product.

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Address for fiber installation

Primary contact person

On-site technical contact

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