Belgian Internet Provider
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SUBSCRIPTION FORM

- Rubrics marked with a * are very important.
  Without them, we do not guarantee the registration of your access.

 
Name *
Surname *
Company
Adress *
State *
Zip Code *
Country *
Phone Number *
Fax
VAT N°
Your e-mail adress or one of your company *
Le nom de votre ancien fournisseur d'accés *
Choice of the kind of subscription

My subscriptin will be :
Phone Number to activate : 
Kind of line :
Line with alarm :
Answer wanted by :   
Applicant declares on honour that information introduced above is correct and binds to the approval of this contract and the definitive payment of this subscription.

I Agree 

  

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