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Personal data

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

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

Country Code {{errorMessages.CLECountry.required}} {{errorMessages.CLECountry}}

Phone Number {{errorMessages.CLEPhone.required}} {{errorMessages.CLEPhone.pattern}} {{errorMessages.CLEPhone.pattern}} {{errorMessages.CLEPhone.pattern}} {{errorMessages.CLEPhone}} {{errorMessages.CLEPhone.pattern}}

Email address {{errorMessages.MAILBACKADDR.required}} {{errorMessages.MAILBACKADDR.pattern}} Please match the e-mail address above {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR}} {{errorMessages.MAILBACKADDR.pattern}}

Installation address

{{errorMessages.lomKey}} The field is mandatory

Box number (optional) {{errorMessages.boxnumber.required}} {{errorMessages.boxnumber.pattern}} {{errorMessages.boxnumber.pattern}} {{errorMessages.boxnumber.pattern}} {{errorMessages.boxnumber}} {{errorMessages.boxnumber.pattern}}

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To stay informed about the arrival of fiber at your address and other Proximus products and services, check the box below.

I would like to be kept informed about Proximus products, services, contests and promotions that may be of interest to me. To this end, Proximus, as data controller, may store my personal data (the data on this form and the context in which they were collected) in its records in order to personalize communications based on my interests, inferred from my participation to events and contests, and may contact me, including by phone and via electronic channels (email, and/or text message/SMS). I know that I have the right to withdraw my consent at any time and that my data is processed in accordance with the Proximus privacy policy, which informs me how to adjust my privacy settings and how to withdraw my consent.

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Installation address

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