<link rel="stylesheet" href="/blocks/form/form.css">
<div class="form">
<form class="ebs-form-fr"
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/dispute-charge/submission-confirmation">
<select id="recordType" name="recordType" hidden>
<option value="012QU000001EJwp">EBS</option>
</select>
<input type="hidden" name="origin" value="Web">
<input type="hidden" name="status" value="New">
<input type="hidden" name="priority" value="Medium">
<input type="hidden" name="supportsRedirect" value="true">
<div class="text-wrapper field-wrapper">
<label for="company">Nom du client :</label>
<input id="company" maxlength="80" name="company" size="20" type="text">
</div>
<div class="text-wrapper field-wrapper">
<label for="name">Nom du contact :</label>
<input id="name" maxlength="80" name="name" size="20" type="text">
</div>
<div class="text-wrapper field-wrapper">
<label for="email">Courriel :</label>
<input id="email" maxlength="80" name="email" size="20" type="text" required>
</div>
<span id="emailError" style="color:red;font-size:12px;"></span>
<div class="text-wrapper field-wrapper">
<label for="phone">Téléphone :</label>
<input id="phone" maxlength="40" name="phone" size="20" type="text" required>
</div>
<span id="phoneError" style="color:red;font-size:12px;"></span>
<div class="text-wrapper field-wrapper">
<label for="00NQU000003PQuq">Numéro de compte :</label>
<input id="00NQU000003PQuq" maxlength="255" name="00NQU000003PQuq" size="20" type="text" required>
</div>
<div class="text-wrapper field-wrapper">
<label for="subject">Sujet :</label>
<input id="subject" maxlength="80" name="subject" size="20" type="text" required>
</div>
<div class="text-wrapper field-wrapper">
<label for="00NQU000003PR2p">Numéro PRO :</label>
<input id="00NQU000003PR2p" maxlength="255" name="00NQU000003PR2p" size="20" type="text">
</div>
<div class="text-wrapper field-wrapper">
<label for="type">Type :</label>
<select id="type" name="type" required>
<option value="">--Aucun--</option>
<option value="Account/Reference Edits Updates">Account/Reference Edits Updates</option>
<option value="Documentation Request">Documentation Request</option>
<option value="Guaranteed Shipment">Guaranteed Shipment</option>
<option value="Incorrect Debtor">Incorrect Debtor</option>
<option value="Incorrect Rate">Incorrect Rate</option>
<option value="Inspection Review">Inspection Review</option>
<option value="Other Invoicing">Other Invoicing</option>
<option value="Reweigh Review">Reweigh Review</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="subtype">Type de sous-type :</label>
<select id="subtype" name="00NQU000003PRWC" title="Sub Type" required>
<option value="">--Aucun--</option>
</select>
<span class="down-arrow-icon"><svg><use href="#navigational_chevron_down_small"></use></svg></span>
</div>
<div id="categoryDiv" class="text-wrapper field-wrapper" style="display:none;">
<label for="category">Catégorie :</label>
<select id="category" name="00NQU000003PRVA" title="Category">
<option value="">--Aucun--</option>
</select>
<span class="down-arrow-icon"><svg><use href="#navigational_chevron_down_small"></use></svg></span>
</div>
<div id="additionalCommentsDiv" class="text-wrapper field-wrapper" style="display:none;">
<label for="description">Commentaires supplémentaires :</label>
<textarea name="description"></textarea>
</div>
<div id="preferredAccountDiv" class="text-wrapper field-wrapper" style="display:none;">
<label for="preferredAccountNumber">Numéro de compte préféré :</label>
<input type="text" id="preferredAccountNumber" name="00NQU000003PR3E" maxlength="50">
</div>
<div id="otherSurchargeAccessorialDiv" class="text-wrapper field-wrapper" style="display:none;">
<label for="otherSurchargeAccessorial">Autre type de supplément/accessoire :</label>
<input type="text" id="otherSurchargeAccessorial" name="00NQU000003PR2e" maxlength="50">
</div>
<div id="otherSurchargeDiv" class="text-wrapper field-wrapper" style="display:none;">
<label for="otherSurchargeText">Autres suppléments :</label>
<input type="text" id="otherSurchargeText" name="00NQU000003PR2f">
</div>
<div id="rateValidityDiv" class="text-wrapper field-wrapper" style="display:none;">
<label for="rateValidity">Tarif ou validité :</label>
<select id="rateValidity" name="00NQU000003PR3e">
<option value="">--Aucun--</option>
<option value="Rate">Tarif</option>
<option value="Validity">Validité</option>
</select>
</div>
<div id="conditionalError" style="color:red;font-weight:bold;margin-top:5px;"></div>
<div class="button-wrapper field-wrapper submit-wrapper">
<button type="submit" class="button">SOUMETTRE</button>
</div>
</form>
</div>