Request for modification of the Proximus infrastructure

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

Personal data

{{errorMessages.title.required}} {{errorMessages.title.pattern}}
{{errorMessages.FirstName.required}} {{errorMessages.FirstName.pattern}} {{errorMessages.FirstName.pattern}} {{errorMessages.FirstName.pattern}} {{errorMessages.FirstName}} {{errorMessages.FirstName.pattern}}
{{errorMessages.LastName.required}} {{errorMessages.LastName.pattern}} {{errorMessages.LastName.pattern}} {{errorMessages.LastName.pattern}} {{errorMessages.LastName}} {{errorMessages.LastName.pattern}}

Installation address

{{errorMessages.StreetName_Installation.required}} {{errorMessages.StreetName_Installation.pattern}} {{errorMessages.StreetName_Installation.pattern}} {{errorMessages.StreetName_Installation.pattern}} {{errorMessages.StreetName_Installation}} {{errorMessages.StreetName_Installation.pattern}}
{{errorMessages.HouseNumber_Installation.required}} {{errorMessages.HouseNumber_Installation.pattern}} {{errorMessages.HouseNumber_Installation.pattern}} {{errorMessages.HouseNumber_Installation.pattern}} {{errorMessages.HouseNumber_Installation}} {{errorMessages.HouseNumber_Installation.pattern}}
{{errorMessages.Letter_Installation.required}} {{errorMessages.Letter_Installation.pattern}} {{errorMessages.Letter_Installation.pattern}} {{errorMessages.Letter_Installation.pattern}} {{errorMessages.Letter_Installation}} {{errorMessages.Letter_Installation.pattern}}
{{errorMessages.zipCode_Installation.required}} {{errorMessages.zipCode_Installation.pattern}} {{errorMessages.zipCode_Installation.pattern}} {{errorMessages.zipCode_Installation.pattern}} {{errorMessages.zipCode_Installation}} {{errorMessages.zipCode_Installation.pattern}}
{{errorMessages.cityName_Installation.required}} {{errorMessages.cityName_Installation.pattern}} {{errorMessages.cityName_Installation.pattern}} {{errorMessages.cityName_Installation.pattern}} {{errorMessages.cityName_Installation}} {{errorMessages.cityName_Installation.pattern}}
{{errorMessages.contactnumber.required}} {{errorMessages.contactnumber.pattern}}
{{errorMessages.CALLBACKCLI.required}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI}} {{errorMessages.CALLBACKCLI.pattern}}
{{errorMessages.CALLBACKCLI.required}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI}} {{errorMessages.CALLBACKCLI.pattern}}
{{errorMessages.MAILBACKADDR.required}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR}} {{errorMessages.MAILBACKADDR.pattern}}
{{errorMessages.installdate.required}} {{errorMessages.installdate.pattern}} {{errorMessages.installdate.pattern}} {{errorMessages.installdate.pattern}} {{errorMessages.installdate}} {{errorMessages.installdate.pattern}}
{{errorMessages.comments.required}} {{errorMessages.comments.pattern}} {{errorMessages.comments.pattern}} {{errorMessages.comments.pattern}} {{errorMessages.comments}} {{errorMessages.comments.pattern}}

Choose a date, then a time slot when we can contact you

  • There are some time slot free for this date, please pick one on the right.
  • Please fill in all the above required fields so we can propose you time slots
  • We do not find any slots available for the date you selected. Please pick another one.
{{errorMessages.selectedCallbackDate.required}} {{errorMessages.selectedCallbackDate.pattern}} {{errorMessages.selectedCallbackDate.pattern}}

Invoicing address

{{errorMessages.StreetName_Invoice.required}} {{errorMessages.StreetName_Invoice.pattern}} {{errorMessages.StreetName_Invoice.pattern}} {{errorMessages.StreetName_Invoice.pattern}} {{errorMessages.StreetName_Invoice}} {{errorMessages.StreetName_Invoice.pattern}}
{{errorMessages.HouseNumber_Invoice.required}} {{errorMessages.HouseNumber_Invoice.pattern}} {{errorMessages.HouseNumber_Invoice.pattern}} {{errorMessages.HouseNumber_Invoice.pattern}} {{errorMessages.HouseNumber_Invoice}} {{errorMessages.HouseNumber_Invoice.pattern}}
{{errorMessages.Letter_Invoice.required}} {{errorMessages.Letter_Invoice.pattern}} {{errorMessages.Letter_Invoice.pattern}} {{errorMessages.Letter_Invoice.pattern}} {{errorMessages.Letter_Invoice}} {{errorMessages.Letter_Invoice.pattern}}
{{errorMessages.zipCode_Invoice.required}} {{errorMessages.zipCode_Invoice.pattern}} {{errorMessages.zipCode_Invoice.pattern}} {{errorMessages.zipCode_Invoice.pattern}} {{errorMessages.zipCode_Invoice}} {{errorMessages.zipCode_Invoice.pattern}}
{{errorMessages.cityName_Invoice.required}} {{errorMessages.cityName_Invoice.pattern}} {{errorMessages.cityName_Invoice.pattern}} {{errorMessages.cityName_Invoice.pattern}} {{errorMessages.cityName_Invoice}} {{errorMessages.cityName_Invoice.pattern}}

Please wait, your data is being processed

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