Cancellation form

Please fill in the form to cancel your subscription for the following products: Mobile, Internet , Landline , Television.

Note: in the event of someone close to you dies, you can also take over part or all of the Proximus services of the deceased for free.

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

Your personal data

Title {{errorMessages.title.required}} {{errorMessages.title.pattern}}

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

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

Street {{errorMessages.street.required}} {{errorMessages.street.pattern}} {{errorMessages.street.pattern}} {{errorMessages.street.pattern}} {{errorMessages.street}} {{errorMessages.street.pattern}}

Number {{errorMessages.number.required}} {{errorMessages.number.pattern}} {{errorMessages.number.pattern}} {{errorMessages.number.pattern}} {{errorMessages.number}} {{errorMessages.number.pattern}}

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

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

City {{errorMessages.city.required}} {{errorMessages.city.pattern}} {{errorMessages.city.pattern}} {{errorMessages.city.pattern}} {{errorMessages.city}} {{errorMessages.city.pattern}}

E-mail address {{errorMessages.email.required}} {{errorMessages.email.pattern}} {{errorMessages.email.pattern}} {{errorMessages.email.pattern}} {{errorMessages.email}} {{errorMessages.email.pattern}}

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

Customer number: (as mentioned on your Proximus bill or payment statement) (optional) {{errorMessages.customer_id.required}} {{errorMessages.customer_id.pattern}} {{errorMessages.customer_id.pattern}} {{errorMessages.customer_id.pattern}} {{errorMessages.customer_id}} {{errorMessages.customer_id.pattern}}

Main reason (optional) (optional)

Announced price increase {{errorMessages.reason.required}} {{errorMessages.reason.pattern}}

Price too high {{errorMessages.reason.required}} {{errorMessages.reason.pattern}}

Leaving country {{errorMessages.reason.required}} {{errorMessages.reason.pattern}}

Other {{errorMessages.reason.required}} {{errorMessages.reason.pattern}}

Do you want to cancel your Internet subscription? {{errorMessages.internet_cancel.required}} {{errorMessages.internet_cancel.pattern}}

Phone/line number of your Internetsubscription {{errorMessages.internet1.required}} {{errorMessages.internet1.pattern}} {{errorMessages.internet1.pattern}} {{errorMessages.internet1.pattern}} {{errorMessages.internet1}} {{errorMessages.internet1.pattern}}

Phone/line number of your Internetsubscription(2) (optional) {{errorMessages.internet2.required}} {{errorMessages.internet2.pattern}} {{errorMessages.internet2.pattern}} {{errorMessages.internet2.pattern}} {{errorMessages.internet2}} {{errorMessages.internet2.pattern}}

Phone/line number of your Internetsubscription(3) (optional) {{errorMessages.internet3.required}} {{errorMessages.internet3.pattern}} {{errorMessages.internet3.pattern}} {{errorMessages.internet3.pattern}} {{errorMessages.internet3}} {{errorMessages.internet3.pattern}}

Do you want to cancel your Tv subscription? {{errorMessages.tv_cancel.required}} {{errorMessages.tv_cancel.pattern}}

Phone/line number of your TV subscription {{errorMessages.tv.required}} {{errorMessages.tv.pattern}} {{errorMessages.tv.pattern}} {{errorMessages.tv.pattern}} {{errorMessages.tv}} {{errorMessages.tv.pattern}}

Do you want to cancel your mobile phone subscription? {{errorMessages.gsm_cancel.required}} {{errorMessages.gsm_cancel.pattern}}

Mobile phone number (1) you want to cancel {{errorMessages.gsm1.required}} {{errorMessages.gsm1.pattern}} {{errorMessages.gsm1.pattern}} {{errorMessages.gsm1.pattern}} {{errorMessages.gsm1}} {{errorMessages.gsm1.pattern}}

Mobile phone number (2) you want to cancel (optional) {{errorMessages.gsm2.required}} {{errorMessages.gsm2.pattern}} {{errorMessages.gsm2.pattern}} {{errorMessages.gsm2.pattern}} {{errorMessages.gsm2}} {{errorMessages.gsm2.pattern}}

Mobile phone number (3) you want to cancel (optional) {{errorMessages.gsm3.required}} {{errorMessages.gsm3.pattern}} {{errorMessages.gsm3.pattern}} {{errorMessages.gsm3.pattern}} {{errorMessages.gsm3}} {{errorMessages.gsm3.pattern}}

Do you want to cancel your landline subscription? {{errorMessages.fix_cancel.required}} {{errorMessages.fix_cancel.pattern}}

Landline number(1) you want to cancel {{errorMessages.fix1.required}} {{errorMessages.fix1.pattern}} {{errorMessages.fix1.pattern}} {{errorMessages.fix1.pattern}} {{errorMessages.fix1}} {{errorMessages.fix1.pattern}}

Landline number(2) you want to cancel (optional) {{errorMessages.fix2.required}} {{errorMessages.fix2.pattern}} {{errorMessages.fix2.pattern}} {{errorMessages.fix2.pattern}} {{errorMessages.fix2}} {{errorMessages.fix2.pattern}}

Landline number(3) you want to cancel (optional) {{errorMessages.fix3.required}} {{errorMessages.fix3.pattern}} {{errorMessages.fix3.pattern}} {{errorMessages.fix3.pattern}} {{errorMessages.fix3}} {{errorMessages.fix3.pattern}}

Possible remarks (optional) {{errorMessages.remark.required}} {{errorMessages.remark.pattern}} {{errorMessages.remark.pattern}} {{errorMessages.remark.pattern}} {{errorMessages.remark}} {{errorMessages.remark.pattern}}

Date of executing the cancellation {{errorMessages.date_cancel.required}} {{errorMessages.date_cancel.pattern}} {{errorMessages.date_cancel.pattern}} {{errorMessages.date_cancel.pattern}} {{errorMessages.date_cancel}} {{errorMessages.date_cancel.pattern}}

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 policy which informs me how to manage my privacy settings.

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