NETnet HOME Classic

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

--------------------------------------------------------------------------------------
CONTRACT FOR FREE ACCESS TO THE SERVICE OF
" NETnet HOME 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		Nationality :	B
Date of birth	/ /		Other

B. 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°/

C. PAYMENT OPTIONS

Choose one of the following options

DOMICILIATION
I'm signing below, requesting the company 'NETnet', from today to debit all invoices with referring or telephone number:

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 : ___________________________________

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 HOME Classic'

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

I would like to activate 'Pre- Selection' (all calls go automaticly over the NETnet network).

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 HOME CLassic» of NETnet and I accept these.

in on / /

Singature,___________________________