Contactformulier

Gelieve het formulier in te vullen om je abonnement op één van de volgende producten op te zeggen: Mobile, Internet, Vaste lijn, Televisie.

Alle velden zijn verplicht, behalve die waar "optioneel" staat.

Bedrijfsgegevens

{{errorMessages.companyname.required}} {{errorMessages.companyname.pattern}} {{errorMessages.companyname.pattern}} {{errorMessages.companyname.pattern}} {{errorMessages.companyname}} {{errorMessages.companyname.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.MAILBACKADDR.required}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR}} {{errorMessages.MAILBACKADDR.pattern}}
{{errorMessages.CALLBACKCLICountry.required}} {{errorMessages.CALLBACKCLICountry}}
{{errorMessages.CALLBACKCLIPhone.required}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone}} {{errorMessages.CALLBACKCLIPhone.pattern}}
{{errorMessages.street.required}} {{errorMessages.street.pattern}} {{errorMessages.street.pattern}} {{errorMessages.street.pattern}} {{errorMessages.street}} {{errorMessages.street.pattern}}
{{errorMessages.number.required}} {{errorMessages.number.pattern}} {{errorMessages.number.pattern}} {{errorMessages.number.pattern}} {{errorMessages.number}} {{errorMessages.number.pattern}}
{{errorMessages.box.required}} {{errorMessages.box.pattern}} {{errorMessages.box.pattern}} {{errorMessages.box.pattern}} {{errorMessages.box}} {{errorMessages.box.pattern}}
{{errorMessages.zip.required}} {{errorMessages.zip.pattern}} {{errorMessages.zip.pattern}} {{errorMessages.zip.pattern}} {{errorMessages.zip}} {{errorMessages.zip.pattern}}
{{errorMessages.city.required}} {{errorMessages.city.pattern}} {{errorMessages.city.pattern}} {{errorMessages.city.pattern}} {{errorMessages.city}} {{errorMessages.city.pattern}}
{{errorMessages.customer_id.required}} {{errorMessages.customer_id.pattern}} {{errorMessages.customer_id.pattern}} {{errorMessages.customer_id.pattern}} {{errorMessages.customer_id}} {{errorMessages.customer_id.pattern}}
Hoofdreden
{{errorMessages.reason.required}} {{errorMessages.reason.pattern}}
{{errorMessages.reason.required}} {{errorMessages.reason.pattern}}
{{errorMessages.reason.required}} {{errorMessages.reason.pattern}}
{{errorMessages.reason.required}} {{errorMessages.reason.pattern}}
{{errorMessages.reason.required}} {{errorMessages.reason.pattern}}

Gelieve te verduidelijken welke produkten je wenst op te zeggen

{{errorMessages.internet_cancel.required}} {{errorMessages.internet_cancel.pattern}}
{{errorMessages.internet1.required}} {{errorMessages.internet1.pattern}} {{errorMessages.internet1.pattern}} {{errorMessages.internet1.pattern}} {{errorMessages.internet1}} {{errorMessages.internet1.pattern}}
{{errorMessages.internet2.required}} {{errorMessages.internet2.pattern}} {{errorMessages.internet2.pattern}} {{errorMessages.internet2.pattern}} {{errorMessages.internet2}} {{errorMessages.internet2.pattern}}
{{errorMessages.internet3.required}} {{errorMessages.internet3.pattern}} {{errorMessages.internet3.pattern}} {{errorMessages.internet3.pattern}} {{errorMessages.internet3}} {{errorMessages.internet3.pattern}}
{{errorMessages.tv_cancel.required}} {{errorMessages.tv_cancel.pattern}}
{{errorMessages.tv.required}} {{errorMessages.tv.pattern}} {{errorMessages.tv.pattern}} {{errorMessages.tv.pattern}} {{errorMessages.tv}} {{errorMessages.tv.pattern}}

Hou je apparatuur goed bij, meer informatie zal volgen via de bevestigingsbrief die je binnenkort in je bus mag verwachten.

{{errorMessages.gsm_cancel.required}} {{errorMessages.gsm_cancel.pattern}}
{{errorMessages.gsm1.required}} {{errorMessages.gsm1.pattern}} {{errorMessages.gsm1.pattern}} {{errorMessages.gsm1.pattern}} {{errorMessages.gsm1}} {{errorMessages.gsm1.pattern}}
{{errorMessages.gsm2.required}} {{errorMessages.gsm2.pattern}} {{errorMessages.gsm2.pattern}} {{errorMessages.gsm2.pattern}} {{errorMessages.gsm2}} {{errorMessages.gsm2.pattern}}
{{errorMessages.gsm3.required}} {{errorMessages.gsm3.pattern}} {{errorMessages.gsm3.pattern}} {{errorMessages.gsm3.pattern}} {{errorMessages.gsm3}} {{errorMessages.gsm3.pattern}}
{{errorMessages.fix_cancel.required}} {{errorMessages.fix_cancel.pattern}}
{{errorMessages.fix1.required}} {{errorMessages.fix1.pattern}} {{errorMessages.fix1.pattern}} {{errorMessages.fix1.pattern}} {{errorMessages.fix1}} {{errorMessages.fix1.pattern}}
{{errorMessages.fix2.required}} {{errorMessages.fix2.pattern}} {{errorMessages.fix2.pattern}} {{errorMessages.fix2.pattern}} {{errorMessages.fix2}} {{errorMessages.fix2.pattern}}
{{errorMessages.fix3.required}} {{errorMessages.fix3.pattern}} {{errorMessages.fix3.pattern}} {{errorMessages.fix3.pattern}} {{errorMessages.fix3}} {{errorMessages.fix3.pattern}}
{{errorMessages.remark.required}} {{errorMessages.remark.pattern}}
{{errorMessages.date_cancel.required}} {{errorMessages.date_cancel.pattern}} {{errorMessages.date_cancel.pattern}} {{errorMessages.date_cancel.pattern}} {{errorMessages.date_cancel}} {{errorMessages.date_cancel.pattern}}

Proximus behandelt je aanvraag binnen maximum één week.

Even geduld, je gegevens worden verwerkt

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