Instructions :
1. Fill in all fields
2. Print out this page and sign it *
3. Send the application to us by fax or post

TELonline
Nierstraat 16
3590 Diepenbeek
or fax 011/ 72.32.03

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CONTRACT FOR FREE ACCESS TO THE SERVICE OF
 " NETnet Business Classic"
A. CUSTOMER INFORMATION

REP CODE : CD2 R0152  - TELonline

Name :
Firstname :
Address : Nbr :

Apt :
Postal code :
Place :

Average monthly usage BEF
Language :   N   F   E   D

B.T.W. :  :  

 BE   * vrijgesteld van BTW  ja       nee
B. INVOICING ADDRESS (if different from above)
name:
Address : Nr :   Apt :

 Place :

 Postalcode
VAT BE H.R
 
C. REQUEST FOR FREE ACCESS
Yes, I want free acces and without any obligation access to the network of NETnet via «NETnet Home classic» . These are my telephoen numbers, from which I want to use «NETnet HOME Classic»:

1°/    2°/
3°/    4°/

5°/    6°/
7°/    8°/
D. PAYMENT OPTIONS

Choose one of the following 3 options

 

  1. BANK WITHDRAWAL (DOMICILIATION)

Signed, company name:

Requests the company:
NETnet
Excelsiorlaan 89
1930 Zaventem

to debit, as from today and untill further notice, all invoices with referte or abonneenummer

* to complete by NETnet NETnet :__________________________________________

To receive from following financial institute ::
Name Bank
Address Bank:
Postal code:

Place:

by debit from my account nbr://

*Signature_______________________________

Identificatienummer van de schuldeiser : 004-6154985-3X

RESERVED FOR THE FINANCIAL INSTITUTION
De hierboven vermelde domiciliėring werd

Aanvaard onder nummer :_________________________________

Domiciliėringsnummer:___________________________________

Datum ___/___  /___        Stempel en handtekening_________________________

 

to complete by NETnet:

From my bank account :--

To receive from my financial institution:

Bank Name :

Address:

Postal code :

Place :
Identificatienummer van de schuldeiser : 00461549853

* Singature of account holder : ___________________________________
  1. PAYMENT BY CREDIT CARD

Hereby and from today, untill further notice, I allow the company NETnet to debit my credit card for all invoices commited to this contract:

Visa  

 Eurocard/Mastercard

Nr. Credit card :

Exp. date :

 / /

Name of the cardholder:

* Handtekening van de kaarthouder____________________________

D. ADDITIONAL SERVICES

I already have a '1588' contract with NETnet and I switch to 'NETnet BUSINESS Classic'

I would like to have a detailed invoice an pay 25 Bef / month extra.

I would like to activate 'Pre- Selection' (on the numbers mentioned under item C).

NETnet sends me an invoice every month with a clear review of all my national and international calls which I made through the NEtnet network.

I declare to have knowledge of hte contract, as well as the general conditions of the contract and the rates of the service «NETnet BUSINESS CLassic» of NETnet and I accept these.

 in on / /

 

Signature,___________________________