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

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{{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.residence.required}} {{errorMessages.residence.pattern}} {{errorMessages.residence.pattern}} {{errorMessages.residence.pattern}} {{errorMessages.residence}} {{errorMessages.residence.pattern}}
{{errorMessages.lomKey}} The field is mandatory
{{errorMessages.CALLBACKCLICountry.required}} {{errorMessages.CALLBACKCLICountry}}
{{errorMessages.CALLBACKCLIPhone.required}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone.pattern}} {{errorMessages.CALLBACKCLIPhone}} {{errorMessages.CALLBACKCLIPhone.pattern}}
{{errorMessages.MAILBACKADDR.required}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR.pattern}} {{errorMessages.MAILBACKADDR}} {{errorMessages.MAILBACKADDR.pattern}}

Pick a date, then pick a slot

  • There are some time slot free for this date, please pick one on the right.
  • 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}}

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