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Data

Name of the company from which you received this promotion {{errorMessages.promoter.required}} {{errorMessages.promoter.pattern}} {{errorMessages.promoter.pattern}} {{errorMessages.promoter.pattern}} {{errorMessages.promoter}} {{errorMessages.promoter.pattern}}

First Name {{errorMessages.FirstName.required}} {{errorMessages.FirstName.pattern}} {{errorMessages.FirstName.pattern}} {{errorMessages.FirstName.pattern}} {{errorMessages.FirstName}} {{errorMessages.FirstName.pattern}}

Name {{errorMessages.LastName.required}} {{errorMessages.LastName.pattern}} {{errorMessages.LastName.pattern}} {{errorMessages.LastName.pattern}} {{errorMessages.LastName}} {{errorMessages.LastName.pattern}}

Landcode {{errorMessages.CALLBACKCLICountry.required}} {{errorMessages.CALLBACKCLICountry}}

Your phone number to reach you quickly {{errorMessages.CALLBACKCLIPhone.required}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone}} {{errorMessages.CALLBACKCLIPhone.pattern}}

Email address {{errorMessages.MAILBACKADDR.required}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR}} {{errorMessages.MAILBACKADDR.pattern}}

Indicative activation date of the pack {{errorMessages.date.required}} {{errorMessages.date.pattern}} {{errorMessages.date.pattern}} {{errorMessages.date.pattern}} {{errorMessages.date}} {{errorMessages.date.pattern}}

Remarks (optional) {{errorMessages.remarks.required}} {{errorMessages.remarks.pattern}} {{errorMessages.remarks.pattern}} {{errorMessages.remarks.pattern}} {{errorMessages.remarks}} {{errorMessages.remarks.pattern}}

New address

Street or projectname {{errorMessages.street2.required}} {{errorMessages.street2.pattern}} {{errorMessages.street2.pattern}} {{errorMessages.street2.pattern}} {{errorMessages.street2}} {{errorMessages.street2.pattern}}

Number {{errorMessages.number2.required}} {{errorMessages.number2.pattern}} {{errorMessages.number2.pattern}} {{errorMessages.number2.pattern}} {{errorMessages.number2}} {{errorMessages.number2.pattern}}

Box (optional) {{errorMessages.box2.required}} {{errorMessages.box2.pattern}} {{errorMessages.box2.pattern}} {{errorMessages.box2.pattern}} {{errorMessages.box2}} {{errorMessages.box2.pattern}}

Zip code {{errorMessages.zip2.required}} {{errorMessages.zip2.pattern}} {{errorMessages.zip2.pattern}} {{errorMessages.zip2.pattern}} {{errorMessages.zip2}} {{errorMessages.zip2.pattern}}

City {{errorMessages.city2.required}} {{errorMessages.city2.pattern}} {{errorMessages.city2.pattern}} {{errorMessages.city2.pattern}} {{errorMessages.city2}} {{errorMessages.city2.pattern}}

I declare that I have taken note of the conditions¹ of this action and the consumer information² and accept them.

Yes {{errorMessages.geaanvaard.required}} {{errorMessages.geaanvaard.pattern}}

In addition to the general terms and conditions of Proximus, the following specific conditions apply.
Consumer info on www.proximus.be/consumerinfo

Thank you for your confidence.

Mynewhome team

mynewhome@proximus.com

I would like to be kept informed about products, services, contests and promotions of Proximus. To this end, Proximus may store my personal data in its files and may contact me, including by phone and via electronic channels such as e-mail, SMS and social media. I’m aware that my data is processed in accordance with Proximus' privacy notice which informs me how to manage my privacy settings.

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