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19
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1
ID Proximus
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2
Sales ID
*
Dit veld is verplicht.
Cihan
Frederik
Jaimi
Junior
Kerstin
Steven
Cihan
Frederik
Jaimi
Junior
Kerstin
Steven
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3
Sales ID Email
example@example.com
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4
Naam/Firmanaam
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5
Voornaam
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6
Adres
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7
Nr
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8
Bus
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9
Postcode
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10
Gemeente
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11
Klanten rekeningnummer bij Proximus
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12
Btw
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13
E mailadres
example@example.com
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14
Gsm nr
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Dit veld is verplicht.
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15
Simkaart Nr
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16
Wanneer mag de conversie uitgevoerd worden
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17
Wanneer mag de conversie uitgevoerd worden?
Datum
Dag
Maand
Jaar
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18
Geef uw reden op:
Nummer niet in gebruik, Werknemer verlaat Firma.....
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19
Datum
Datum
Dag
Maand
Jaar
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20
Getekend te
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21
ID uploaden
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