<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">

<link rel="stylesheet" href="/blocks/form/form.css">

<div class="form block">

<form class="embed-form" action="https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8&orgId=00DfI00000Ng3jD" method="POST">

<input type="hidden" name="orgid" value="00DfI00000Ng3jD">

<input type="hidden" name="retURL" value="https://www.fedexfreight.com/en-us/manage-account/billing/support/submission-confirmation">

<div class="drop-down-wrapper field-wrapper">

<label for="00NQU000003PR49">Request Type</label>

<select id="00NQU000003PR49" name="00NQU000003PR49" required>

<option value="">--None--</option>

<option value="How to register an account for FedEx Freight Billing Online">How to register an account for FedEx Freight Billing Online</option>

<option value="How to dispute a charge">How to dispute a charge</option>

<option value="How to create a payment profile">How to create a payment profile</option>

<option value="How to edit/update a payment profile">How to edit/update a payment profile</option>

<option value="How to process a payment">How to process a payment</option>

<option value="How to setup autopay">How to setup autopay</option>

<option value="How to cancel a FedEx Freight Billing Online payment">How to cancel a FedEx Freight Billing Online payment</option>

<option value="How to edit/remove accounts">How to edit/remove accounts</option>

<option value="How to add/remove a user">How to add/remove a user</option>

<option value="How to view an invoice copy">How to view an invoice copy</option>

<option value="How to get an adjusted invoice on FedEx Freight Billing Online">How to get an adjusted invoice on FedEx Freight Billing Online</option>

<option value="How to create reporting/downloads">How to create reporting/downloads</option>

<option value="How to download custom documents">How to download custom documents</option>

<option value="How to change a FedEx Freight Billing Online administrator">How to change a FedEx Freight Billing Online administrator</option>

<option value="How to search FedEx Freight Billing Online">How to search FedEx Freight Billing Online</option>

<option value="How to unregister an account from FedEx Freight Billing Online">How to unregister an account from FedEx Freight Billing Online</option>

<option value="Technical Support">Technical Support</option>

</select>

</div>

<div class="text-wrapper field-wrapper">

<label>Contact Name</label>

<input id="name" maxlength="255" name="name" type="text" required>

</div>

<div class="text-wrapper field-wrapper">

<label>Contact Email</label>

<input id="email" maxlength="80" name="email" type="text" required>

</div>

<div class="text-wrapper field-wrapper">

<label>Contact Phone</label>

<input id="phone" maxlength="255" name="phone" type="text">

</div>

<div class="text-wrapper field-wrapper">

<label>Customer Account Number</label>

<input id="00NQU000003PQz1" name="00NQU000003PQz1" type="text">

</div>

<div class="text-wrapper field-wrapper">

<label>Invoice Number</label>

<input id="00NQU000003PR18" name="00NQU000003PR18" type="text">

</div>

<div class="text-wrapper field-wrapper">

<label>Comments</label>

<textarea id="00NQU000003PQyW" name="00NQU000003PQyW" rows="3"></textarea>

</div>

<div class="text-wrapper field-wrapper">

<label>Call Back Requested Date</label>

<input class="dateInput" id="cbReqDate" name="cbReqDate" type="datetime-local" required>

</div>

<div class="text-wrapper field-wrapper">

<label>Call Back</label>

<input id="00NQU000003PQxi" name="00NQU000003PQxi" type="checkbox" value="1">

</div>

<select id="recordType" name="recordType" hidden>

<option value="012QU000001EJwt">FBO Support</option>

</select>

<select id="priority" name="priority" hidden>

<option value="Medium">Medium</option>

</select>

<select id="type" name="type" hidden>

<option value="FXF FBO Support">FXF FBO Support</option>

</select>

<select id="status" name="status" hidden>

<option value="New">New</option>

</select>

<input id="00NQU000003PQxh" name="00NQU000003PQxh" type="text" hidden>

<input id="subject" name="subject" type="text" hidden>

<div class="button-wrapper field-wrapper submit-wrapper">

<button type="submit" class="button">SUBMIT</button>

</div>

</form>

</div>

<script>

document.getElementById('cbReqDate').addEventListener('blur', function() {

const dateField = document.getElementById('cbReqDate');

if (dateField.value) {

const date = new Date(dateField.value);

const formatted =

date.toLocaleDateString('en-US',{month:'2-digit',day:'2-digit',year:'numeric'}) +

', ' +

date.toLocaleTimeString('en-US',{hour:'2-digit',minute:'2-digit',hour12:true});

document.getElementById('00NQU000003PQxh').value = formatted;

}

});

document.getElementById('00NQU000003PR49').addEventListener('blur', function() {

const reqType = document.getElementById('00NQU000003PR49');

if (reqType.value) {

document.getElementById('subject').value = reqType.value;

}

});

</script>