Fiber request form

Please fill in your data so we can process your free installation of the fiber from the street to your house.

By submitting this form, I consent to Proximus, the data controller, recording my personal data entered on this form in its files with a view to contacting me by telephone, post and/or digital channels (email and/or SMS) to inform me of the roll-out of fiber in order for me to receive all commercial offers relating to the same. I have the right to withdraw my consent at any time. My data is processed in accordance with the Proximus privacy policy, which informs me how to withdraw my consent.

Your personal data

Phone number (fixed/mobile) or customer number if you are a Proximus customer (optional) {{errorMessages.phoneOrCustomerNumber.required}} {{errorMessages.phoneOrCustomerNumber.pattern}} {{errorMessages.phoneOrCustomerNumber.pattern}} {{errorMessages.phoneOrCustomerNumber.pattern}} {{errorMessages.phoneOrCustomerNumber}} {{errorMessages.phoneOrCustomerNumber.pattern}}

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}}

Residence Name (optional) {{errorMessages.residence.required}} {{errorMessages.residence.pattern}} {{errorMessages.residence.pattern}} {{errorMessages.residence.pattern}} {{errorMessages.residence}} {{errorMessages.residence.pattern}}

{{errorMessages.lomKey}} The field is mandatory

Country Code {{errorMessages.CALLBACKCLICountry.required}} {{errorMessages.CALLBACKCLICountry}}

Your phone number to reach you quickly (optional) {{errorMessages.CALLBACKCLIPhone.required}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone}} {{errorMessages.CALLBACKCLIPhone.pattern}}

E-mail address (optional) {{errorMessages.MAILBACKADDR.required}} {{errorMessages.MAILBACKADDR.pattern}} Please match the e-mail address above {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR}} {{errorMessages.MAILBACKADDR.pattern}}

Pick a date, then pick a slot

Date of your appointment (ex: 05/08/2024)

There are some time slots free for this date, please pick one below.
Please fill in all the above required fields so we can propose you time slots
We do not find any slots available for the date you selected. Please pick another one.

{{errorMessages.selectedCallbackDate.required}} {{errorMessages.selectedCallbackDate.pattern}} {{errorMessages.selectedCallbackDate.pattern}}

Communication preferences

Check the box below if you wish to receive other communications from Proximus, not specific to fiber

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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iPhone 16

Fiber request form

Your personal data

Pick a date, then pick a slot

Communication preferences

Join us

Fiber request form

Your personal data

Pick a date, then pick a slot

Communication preferences

Please wait, your data is being processed

Join us