Application for participation

You are a provider of social App and would like to participate to the Offer, fill in the form hereunder.

Only 1 App per application form.

One form must be filled in per App

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

Company

Company name {{errorMessages.companyname.required}} {{errorMessages.companyname.pattern}} {{errorMessages.companyname}}

Enterprise number {{errorMessages.vat.required}} {{errorMessages.vat.pattern}} {{errorMessages.vat}}

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

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

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

Zipcode {{errorMessages.zipcode.required}} {{errorMessages.zipcode.pattern}} {{errorMessages.zipcode}}

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

Contact

Commercial contact person

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

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

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

Countrycode eg +32 {{errorMessages.countrycode.required}} {{errorMessages.countrycode.pattern}} {{errorMessages.countrycode}}

Contactnumber {{errorMessages.telefoon.required}} {{errorMessages.telefoon.pattern}} {{errorMessages.telefoon}}

Technical contact person

Is the commercial contactperson same as technical contactperson {{errorMessages.same.required}} {{errorMessages.same.pattern}}

First Name technical contact person {{errorMessages.firstname2.required}} {{errorMessages.firstname2.pattern}} {{errorMessages.firstname2}}

Last Name technical contact person {{errorMessages.name2.required}} {{errorMessages.name2.pattern}} {{errorMessages.name2}}

Email address technical contact person {{errorMessages.emailtech.required}} {{errorMessages.emailtech.pattern}} {{errorMessages.emailtech}}

Countrycode technical contact person {{errorMessages.countrycodetech.required}} {{errorMessages.countrycodetech.pattern}} {{errorMessages.countrycodetech}}

Contactnumber technical contact person {{errorMessages.telefoontech.required}} {{errorMessages.telefoontech.pattern}} {{errorMessages.telefoontech}}

Info about the App

Name of the app (store name) {{errorMessages.appname.required}} {{errorMessages.appname.pattern}} {{errorMessages.appname}}

Description of your app {{errorMessages.description.required}} {{errorMessages.description.pattern}} {{errorMessages.description}}

Link to the app in App Store {{errorMessages.appstore.required}} {{errorMessages.appstore.pattern}} {{errorMessages.appstore}}

Link to the app in Play Store {{errorMessages.playstore.required}} {{errorMessages.playstore.pattern}} {{errorMessages.playstore}}

Technical info about the App

P2P protocol (optional) {{errorMessages.p2pprotocol.required}} {{errorMessages.p2pprotocol.pattern}} {{errorMessages.p2pprotocol}}

IP address of the server {{errorMessages.ip.required}} {{errorMessages.ip.pattern}} {{errorMessages.ip}}

Domain name used by the service {{errorMessages.domain.required}} {{errorMessages.domain.pattern}}

SNI (for HTTPS) (optional) {{errorMessages.sni.required}} {{errorMessages.sni.pattern}} {{errorMessages.sni}}

Protocols (optional) {{errorMessages.protocols.required}} {{errorMessages.protocols.pattern}} {{errorMessages.protocols}}

URL lists (optional) {{errorMessages.url.required}} {{errorMessages.url.pattern}} {{errorMessages.url}}

Portnumbers (optional) {{errorMessages.portnumbers.required}} {{errorMessages.portnumbers.pattern}} {{errorMessages.portnumbers}}

General Terms & Conditions

I have read and agreed with the General Terms & Conditions for the participation of the Content Partner in the Zero Rating Offer of Proximus SA

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. Proximus may share my data with its subsidiary Scarlet. I’m aware that my data is processed in accordance with Proximus' privacy policy which informs me how to manage my privacy settings.

Do you have a question?

Ask one of our advisors. Make your choice:

Chat with us on this website

Chat with us on this websitenot available at this moment
Forum
Proximus Center