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Domain name request form

Information about your domain name
{{errorMessages.status.required}} {{errorMessages.status.pattern}}
{{errorMessages.domainName.required}} {{errorMessages.domainName.pattern}}
{{errorMessages.importAuthorisationCode.required}} {{errorMessages.importAuthorisationCode.pattern}}
* Mandatory fields
Your information
{{errorMessages.custid.required}} {{errorMessages.custid.pattern}}
{{errorMessages.landline.required}} {{errorMessages.landline.pattern}}
* Mandatory fields
Customer data
{{errorMessages.company.required}} {{errorMessages.company.pattern}}
{{errorMessages.firstname.required}} {{errorMessages.firstname.pattern}}
{{errorMessages.name.required}} {{errorMessages.name.pattern}}
{{errorMessages.address.required}} {{errorMessages.address.pattern}}
{{errorMessages.zipcode.required}} {{errorMessages.zipcode.pattern}}
{{errorMessages.city.required}} {{errorMessages.city.pattern}}
{{errorMessages.vat.required}} {{errorMessages.vat.pattern}}
{{errorMessages.mobile.required}} {{errorMessages.mobile.pattern}}
{{errorMessages.email.required}} {{errorMessages.email.pattern}}
* Mandatory fields
Configuration

Below you can choose the configuration of your domain name. You can change this setting later. In case of doubt, choose the standard configuration.

{{errorMessages.configuration.required}} {{errorMessages.configuration.pattern}}
{{errorMessages.mailservername.required}} {{errorMessages.mailservername.pattern}}
{{errorMessages.ipmailserver.required}} {{errorMessages.ipmailserver.pattern}}
{{errorMessages.webservername.required}} {{errorMessages.webservername.pattern}}
{{errorMessages.ipwebserver.required}} {{errorMessages.ipwebserver.pattern}}
{{errorMessages.connexion.required}} {{errorMessages.connexion.pattern}}
{{errorMessages.dnscloud.required}} {{errorMessages.dnscloud.pattern}}
{{errorMessages.dnsmicrosoft.required}} {{errorMessages.dnsmicrosoft.pattern}}
{{errorMessages.dnsskynet.required}} {{errorMessages.dnsskynet.pattern}}
* Mandatory fields
Hosting rates
{{errorMessages.hosting.required}} {{errorMessages.hosting.pattern}}
{{errorMessages.hostingwindows.required}} {{errorMessages.hostingwindows.pattern}}
{{errorMessages.hostinglinux.required}} {{errorMessages.hostinglinux.pattern}}

Discover our hosting rates for Windows and Linux here

{{errorMessages.agreement.required}} {{errorMessages.agreement.pattern}}

The following specific terms and conditions apply in addition to the general terms and conditions of Proximus.

* Mandatory fields
{{errorMessages.GDPRoptInOptOut.required}} {{errorMessages.GDPRoptInOptOut.pattern}}

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