Proximus infrastructure connection

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}}
{{errorMessages.LastName.required}} {{errorMessages.LastName.pattern}} {{errorMessages.LastName}}
Installation address
{{errorMessages.street.required}} {{errorMessages.street.pattern}} {{errorMessages.street}}
{{errorMessages.number.required}} {{errorMessages.number.pattern}} {{errorMessages.number}}
{{errorMessages.box.required}} {{errorMessages.box.pattern}} {{errorMessages.box}}
{{errorMessages.zip.required}} {{errorMessages.zip.pattern}} {{errorMessages.zip}}
{{errorMessages.city.required}} {{errorMessages.city.pattern}} {{errorMessages.city}}
{{errorMessages.contactnumber.required}} {{errorMessages.contactnumber.pattern}}
{{errorMessages.CALLBACKCLI.required}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI}}
{{errorMessages.CALLBACKCLI.required}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI}}
{{errorMessages.MAILBACKADDR.required}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR}}
{{errorMessages.installdate.required}} {{errorMessages.installdate.pattern}} {{errorMessages.installdate}}
{{errorMessages.comments.required}} {{errorMessages.comments.pattern}} {{errorMessages.comments}}

Pick a date, then pick a slot

  • 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}}
Invoicing address
{{errorMessages.street2.required}} {{errorMessages.street2.pattern}} {{errorMessages.street2}}
{{errorMessages.number2.required}} {{errorMessages.number2.pattern}} {{errorMessages.number2}}
{{errorMessages.box2.required}} {{errorMessages.box2.pattern}} {{errorMessages.box2}}
{{errorMessages.zip2.required}} {{errorMessages.zip2.pattern}} {{errorMessages.zip2}}
{{errorMessages.city2.required}} {{errorMessages.city2.pattern}} {{errorMessages.city2}}

Please wait, your data is being processed

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