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

Your personal data

Title (optional) {{errorMessages.title.required}} {{errorMessages.title.pattern}}

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

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

Installation address

Street {{errorMessages.StreetName.required}} {{errorMessages.StreetName.pattern}} {{errorMessages.StreetName.pattern}} {{errorMessages.StreetName.pattern}} {{errorMessages.StreetName}}

Number {{errorMessages.HouseNumber.required}} {{errorMessages.HouseNumber.pattern}} {{errorMessages.HouseNumber.pattern}} {{errorMessages.HouseNumber.pattern}} {{errorMessages.HouseNumber}}

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

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

City {{errorMessages.cityName.required}} {{errorMessages.cityName.pattern}} {{errorMessages.cityName.pattern}} {{errorMessages.cityName.pattern}} {{errorMessages.cityName}}

Contact number {{errorMessages.contact_number.required}} {{errorMessages.contact_number.pattern}}

Mobile number {{errorMessages.CALLBACKCLI.required}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI}}

Landline number {{errorMessages.CALLBACKCLI.required}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI.pattern}} {{errorMessages.CALLBACKCLI}}

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

Wished installation date {{errorMessages.install_date.required}} {{errorMessages.install_date.pattern}} {{errorMessages.install_date.pattern}} {{errorMessages.install_date.pattern}} {{errorMessages.install_date}}

I'm interested in the following products:

Flex

Epic

Mobilus

Internet

Does a cable for the introduction of the Proximus network already exist at my installation address? {{errorMessages.cable_present.required}} {{errorMessages.cable_present.pattern}}

A cable for the introduction looks like this :

A NTP socket or junction box (apartment) can give an indication that there is a cable for the introduction present :

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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