Demande de modification ou notification de l'infrastructure du câble Proximus en cas de rénovation ou de démolition

Tous les champs sont obligatoires, sauf ceux qui sont mentionnés comme "facultatifs".

Données personelles

{{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}}
{{errorMessages.infrastructure.required}} {{errorMessages.infrastructure.pattern}}
{{errorMessages.infrastructure.required}} {{errorMessages.infrastructure.pattern}}
{{errorMessages.infrastructure.required}} {{errorMessages.infrastructure.pattern}}
{{errorMessages.infrastructure.required}} {{errorMessages.infrastructure.pattern}}

Adresse d'installation

{{errorMessages.region.required}} {{errorMessages.region.pattern}}
{{errorMessages.StreetName.required}} {{errorMessages.StreetName.pattern}} {{errorMessages.StreetName.pattern}} {{errorMessages.StreetName.pattern}} {{errorMessages.StreetName}} {{errorMessages.StreetName.pattern}}
{{errorMessages.HouseNumber.required}} {{errorMessages.HouseNumber.pattern}} {{errorMessages.HouseNumber.pattern}} {{errorMessages.HouseNumber.pattern}} {{errorMessages.HouseNumber}} {{errorMessages.HouseNumber.pattern}}
{{errorMessages.Letter.required}} {{errorMessages.Letter.pattern}} {{errorMessages.Letter.pattern}} {{errorMessages.Letter.pattern}} {{errorMessages.Letter}} {{errorMessages.Letter.pattern}}
{{errorMessages.zipCode.required}} {{errorMessages.zipCode.pattern}} {{errorMessages.zipCode.pattern}} {{errorMessages.zipCode.pattern}} {{errorMessages.zipCode}} {{errorMessages.zipCode.pattern}}
{{errorMessages.cityName.required}} {{errorMessages.cityName.pattern}} {{errorMessages.cityName.pattern}} {{errorMessages.cityName.pattern}} {{errorMessages.cityName}} {{errorMessages.cityName.pattern}}
{{errorMessages.CALLBACKCLI.required}} {{errorMessages.CALLBACKCLI.pattern}}
{{errorMessages.mobile.required}} {{errorMessages.mobile.pattern}} {{errorMessages.mobile.pattern}} {{errorMessages.mobile.pattern}} {{errorMessages.mobile}} {{errorMessages.mobile.pattern}}
{{errorMessages.fixnumber.required}} {{errorMessages.fixnumber.pattern}} {{errorMessages.fixnumber.pattern}} {{errorMessages.fixnumber.pattern}} {{errorMessages.fixnumber}} {{errorMessages.fixnumber.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.remarks.required}} {{errorMessages.remarks.pattern}}
{{errorMessages.building_type.required}} {{errorMessages.building_type.pattern}}
Type de changement pour ‘appartement’
{{errorMessages.public_infra.required}} {{errorMessages.public_infra.pattern}}
{{errorMessages.public_infra.required}} {{errorMessages.public_infra.pattern}}
{{errorMessages.public_infra.required}} {{errorMessages.public_infra.pattern}}
{{errorMessages.public_infra.required}} {{errorMessages.public_infra.pattern}}
Type de changement pour ‘maison’
{{errorMessages.private_infra.required}} {{errorMessages.private_infra.pattern}}
{{errorMessages.private_infra.required}} {{errorMessages.private_infra.pattern}}
{{errorMessages.private_infra.required}} {{errorMessages.private_infra.pattern}}
{{errorMessages.private_infra.required}} {{errorMessages.private_infra.pattern}}
Type de changement pour ‘bâtiment commercial’
{{errorMessages.commercial_infra.required}} {{errorMessages.commercial_infra.pattern}}
{{errorMessages.commercial_infra.required}} {{errorMessages.commercial_infra.pattern}}
{{errorMessages.commercial_infra.required}} {{errorMessages.commercial_infra.pattern}}
{{errorMessages.commercial_infra.required}} {{errorMessages.commercial_infra.pattern}}

Veuillez patienter quelques instants, vos données sont en cours de traitement

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