<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/fr-ca/manage-account/billing/support/submission-confirmation">
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: These fields are optional debugging elements. Please uncomment -->
<!-- these lines if you wish to test in debug mode. -->
<!-- <input type="hidden" name="debug" value=1>
<input type="hidden" name="debugEmail" value="jordan.mcclellan@accenture.com"> -->
<div class="drop-down-wrapper field-wrapper">
<label for="00NQU000003PR49">Type de demande *</label>
<select id="00NQU000003PR49" name="00NQU000003PR49" title="Type de demande" required>
<option value="">--Aucune--</option>
<option value="Login Issues">Problèmes de connexion</option>
<option value="Missing Invoices">Factures manquantes</option>
<option value="Profile Setup">Configuration du profil</option>
<option value="Add/Remove Users">Ajouter/Supprimer des utilisateurs</option>
<option value="Payment Support">Support des paiements</option>
<option value="Other Freight Billing Online Issue">Autre problème de facturation du fret en ligne</option>
</select>
<span class="down-arrow-icon"><svg><use href="#navigational_chevron_down_small"></use></svg></span>
</div>
<div class="text-wrapper field-wrapper">
<label for="name">Nom du contact</label>
<input id="name" maxlength="255" name="name" size="20" type="text" />
</div>
<div class="text-wrapper field-wrapper">
<label for="email">Email du contact *</label>
<input id="email" maxlength="80" name="email" size="20" type="text" required/>
</div>
<div class="text-wrapper field-wrapper">
<label for="phone">Téléphone du contact</label>
<input id="phone" maxlength="255" name="phone" size="20" type="text" />
</div>
<div class="text-wrapper field-wrapper">
<label for="00NQU000003PQz1">Numéro de compte client *</label>
<input id="00NQU000003PQz1" name="00NQU000003PQz1" size="20" type="text" required/>
</div>
<div class="text-wrapper field-wrapper">
<label for="00NQU000003PR18">Numéro de facture</label>
<input id="00NQU000003PR18" maxlength="255" name="00NQU000003PR18" size="20" type="text" />
</div>
<div class="text-wrapper field-wrapper">
<label for="00NQU000003PQyW">Décrivez votre problème *</label>
<textarea id="00NQU000003PQyW" name="00NQU000003PQyW" rows="3" wrap="soft" required></textarea>
</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>
<div class="button-wrapper field-wrapper submit-wrapper">
<button type="submit" class="button">Soumettre</button>
</div>
</form>
</div>