METRO France Widget

Votre email

Sujet

<div class="control-group ticket_section">
                 <label class="  control-label cf_numro_de_carte_metro_839887-label " for="helpdesk_ticket_cf_numro_de_carte_metro_839887">Numéro de carte METRO (sur 22 caractères commençant par 25001)</label>
            <div class="controls   ">
              <input class="  text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_numro_de_carte_metro_839887]" id="helpdesk_ticket_custom_field_cf_numro_de_carte_metro_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_tlphone_839887-label " for="helpdesk_ticket_cf_tlphone_839887">Téléphone</label>
            <div class="controls   ">
              <input class="  text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_tlphone_839887]" id="helpdesk_ticket_custom_field_cf_tlphone_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_entrept_de_contact_839887-label " for="helpdesk_ticket_cf_entrept_de_contact_839887">Entrepôt de contact</label>
            <div class="controls   ">
              <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_entrept_de_contact_839887]" id="helpdesk_ticket_custom_field_cf_entrept_de_contact_839887"><option value="">...</option>
<option data-id="15000030842" value="Agen">Agen</option>
<option data-id="15000030843" value="Aix en Provence">Aix en Provence</option>
<option data-id="15000030844" value="Albertville">Albertville</option>
<option data-id="15000030845" value="Alès">Alès</option>
<option data-id="15000030846" value="Amiens">Amiens</option>
<option data-id="15000030847" value="Angers">Angers</option>
<option data-id="15000030848" value="Anglet">Anglet</option>
<option data-id="15000030849" value="Angoulême">Angoulême</option>
<option data-id="15000030850" value="Annecy">Annecy</option>
<option data-id="15000030851" value="Annemasse">Annemasse</option>
<option data-id="15000030852" value="Auxerre">Auxerre</option>
<option data-id="15000030853" value="Avignon">Avignon</option>
<option data-id="15000030854" value="Belfort">Belfort</option>
<option data-id="15000030855" value="Besançon">Besançon</option>
<option data-id="15000030856" value="Béziers">Béziers</option>
<option data-id="15000030857" value="Bobigny">Bobigny</option>
<option data-id="15000030858" value="Bordeaux Lac">Bordeaux Lac</option>
<option data-id="15000030859" value="Boulogne-sur-Mer">Boulogne-sur-Mer</option>
<option data-id="15000030860" value="Bourg-en-Bresse">Bourg-en-Bresse</option>
<option data-id="15000030861" value="Bourges">Bourges</option>
<option data-id="15000030862" value="Brest">Brest</option>
<option data-id="15000030863" value="Brive-la-Gaillarde">Brive-la-Gaillarde</option>
<option data-id="15000030864" value="Buchelay">Buchelay</option>
<option data-id="15000030865" value="Caen">Caen</option>
<option data-id="15000030866" value="Calais">Calais</option>
<option data-id="15000030867" value="Cannes-la-Bocca ">Cannes-la-Bocca </option>
<option data-id="15000030868" value="Carcassonne">Carcassonne</option>
<option data-id="15000030869" value="Cergy">Cergy</option>
<option data-id="15000030870" value="Chalon-sur-Saône">Chalon-sur-Saône</option>
<option data-id="15000030871" value="Chambéry">Chambéry</option>
<option data-id="15000030872" value="Chamonix">Chamonix</option>
<option data-id="15000030873" value="Charleville-Mézières">Charleville-Mézières</option>
<option data-id="15000030874" value="Chartres">Chartres</option>
<option data-id="15000030875" value="Chennevières-sur-Marne">Chennevières-sur-Marne</option>
<option data-id="15000030876" value="Cherbourg">Cherbourg</option>
<option data-id="15000030877" value="Clermont-Ferrand">Clermont-Ferrand</option>
<option data-id="15000030878" value="Colmar">Colmar</option>
<option data-id="15000030879" value="Creil">Creil</option>
<option data-id="15000030880" value="Epinal">Epinal</option>
<option data-id="15000030881" value="Evry">Evry</option>
<option data-id="15000030882" value="Fréjus">Fréjus</option>
<option data-id="15000030883" value="Gauchy">Gauchy</option>
<option data-id="15000030884" value="Gradignan/Bordeaux">Gradignan/Bordeaux</option>
<option data-id="15000030885" value="Grenoble">Grenoble</option>
<option data-id="15000030886" value="Hénin-Beaumont">Hénin-Beaumont</option>
<option data-id="15000030887" value="La Roche-sur-Yon">La Roche-sur-Yon</option>
<option data-id="15000030888" value="La Rochelle">La Rochelle</option>
<option data-id="15000030889" value="Le Havre">Le Havre</option>
<option data-id="15000030890" value="Le Mans">Le Mans</option>
<option data-id="15000030891" value="Limoges">Limoges</option>
<option data-id="15000030892" value="Lomme">Lomme</option>
<option data-id="15000030893" value="Lorient">Lorient</option>
<option data-id="3010000121758" value="Lyon (Gerland)">Lyon (Gerland)</option>
<option data-id="15000030894" value="Lyon (Limonest)">Lyon (Limonest)</option>
<option data-id="15000030895" value="Lyon (Vaulx-en-Velin)">Lyon (Vaulx-en-Velin)</option>
<option data-id="15000030896" value="Marseille (La Valentine)">Marseille (La Valentine)</option>
<option data-id="15000030897" value="Marseille (les Pennes)">Marseille (les Pennes)</option>
<option data-id="15000030898" value="Meaux">Meaux</option>
<option data-id="15000030899" value="Melun (Vaux Le Pénil)">Melun (Vaux Le Pénil)</option>
<option data-id="15000030900" value="Metz">Metz</option>
<option data-id="15000030901" value="Monaco">Monaco</option>
<option data-id="15000030902" value="Montélimar">Montélimar</option>
<option data-id="15000030903" value="Montpellier">Montpellier</option>
<option data-id="15000030904" value="Mulhouse">Mulhouse</option>
<option data-id="15000030905" value="Nancy">Nancy</option>
<option data-id="15000030906" value="Nanterre">Nanterre</option>
<option data-id="15000030907" value="Nantes">Nantes</option>
<option data-id="15000030908" value="Narbonne">Narbonne</option>
<option data-id="15000030909" value="Nice ">Nice </option>
<option data-id="15000030910" value="Nîmes">Nîmes</option>
<option data-id="15000030911" value="Orléans">Orléans</option>
<option data-id="15000030912" value="Paris 12 - Bercy">Paris 12 - Bercy</option>
<option data-id="15000030913" value="Paris 18 - La chapelle">Paris 18 - La chapelle</option>
<option data-id="15000030914" value="Pau">Pau</option>
<option data-id="15000030915" value="Périgueux">Périgueux</option>
<option data-id="15000030916" value="Perpignan">Perpignan</option>
<option data-id="15000030917" value="Poitiers">Poitiers</option>
<option data-id="15000030918" value="Quimper">Quimper</option>
<option data-id="15000030919" value="Reims">Reims</option>
<option data-id="15000030920" value="Rennes">Rennes</option>
<option data-id="15000030921" value="Rouen">Rouen</option>
<option data-id="15000030922" value="Saint-Brieuc">Saint-Brieuc</option>
<option data-id="15000030923" value="Saint-Etienne">Saint-Etienne</option>
<option data-id="15000030924" value="Saint-Malo">Saint-Malo</option>
<option data-id="15000030925" value="Saint-Nazaire">Saint-Nazaire</option>
<option data-id="15000030926" value="Strasbourg">Strasbourg</option>
<option data-id="15000030927" value="Tarbes">Tarbes</option>
<option data-id="15000030928" value="Toulon">Toulon</option>
<option data-id="15000030929" value="Toulouse (Portet sur Garonne)">Toulouse (Portet sur Garonne)</option>
<option data-id="15000030930" value="Toulouse (Sesquières)">Toulouse (Sesquières)</option>
<option data-id="15000030931" value="Tours">Tours</option>
<option data-id="15000030932" value="Trappes">Trappes</option>
<option data-id="15000030933" value="Troyes">Troyes</option>
<option data-id="15000030934" value="Valence">Valence</option>
<option data-id="15000030935" value="Valenciennes">Valenciennes</option>
<option data-id="15000030936" value="Vannes">Vannes</option>
<option data-id="15000030937" value="Villeneuve-la-Garenne">Villeneuve-la-Garenne</option>
<option data-id="15000030938" value="Vitry-sur-Seine">Vitry-sur-Seine</option>
<option data-id="15000030939" value="Wattrelos">Wattrelos</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_ma_demande_839887-label " for="helpdesk_ticket_cf_ma_demande_839887">Ma demande</label>
            <div class="controls   ">
              <textarea class=" required paragraph section_field span12" rows="6" placeholder="" name="helpdesk_ticket[custom_field][cf_ma_demande_839887]" id="helpdesk_ticket_custom_field_cf_ma_demande_839887">
</textarea>
            </div> 
                </div>

<div class="control-group ticket_section">
                 <label class=" required control-label cf_type_information_839887-label " for="helpdesk_ticket_cf_type_information_839887">Type d'information</label>
            <div class="controls   ">
              <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_type_information_839887]" id="helpdesk_ticket_custom_field_cf_type_information_839887"><option value="">...</option>
<option data-id="3010000100193" value="Détail à apporter pour une livraison">Détail à apporter pour une livraison</option>
<option data-id="3010000100194" value="Délai plus long qu'annoncé, où en est ma livraison ?">Délai plus long qu'annoncé, où en est ma livraison ?</option>
<option data-id="3010000100195" value="Je souhaiterais obtenir ma facture">Je souhaiterais obtenir ma facture</option>
<option data-id="3010000100196" value="Remboursement non reçu">Remboursement non reçu</option>
<option data-id="3010000100197" value="Produit non conforme à la commande">Produit non conforme à la commande</option>
<option data-id="3010000100198" value="Produit reçu finalement non désiré">Produit reçu finalement non désiré</option>
<option data-id="3010000100199" value="Produit reçu endommagé">Produit reçu endommagé</option>
<option data-id="3010000100200" value="Produit défectueux">Produit défectueux</option>
<option data-id="3010000100201" value="Produit manquant">Produit manquant</option>
<option data-id="3010000100202" value="Commande non reçue">Commande non reçue</option>
<option data-id="3010000100203" value="Autre question">Autre question</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_numro_de_carte_metro_839887-label " for="helpdesk_ticket_cf_numro_de_carte_metro_839887">Numéro de carte METRO (sur 22 caractères commençant par 25001)</label>
            <div class="controls   ">
              <input class="  text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_numro_de_carte_metro_839887]" id="helpdesk_ticket_custom_field_cf_numro_de_carte_metro_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_tlphone_839887-label " for="helpdesk_ticket_cf_tlphone_839887">Téléphone</label>
            <div class="controls   ">
              <input class="  text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_tlphone_839887]" id="helpdesk_ticket_custom_field_cf_tlphone_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_numro_de_commande_839887-label " for="helpdesk_ticket_cf_numro_de_commande_839887">Numéro de commande (9-XXXXXXX)</label>
            <div class="controls   ">
              <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_numro_de_commande_839887]" id="helpdesk_ticket_custom_field_cf_numro_de_commande_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_ma_demande_839887-label " for="helpdesk_ticket_cf_ma_demande_839887">Ma demande</label>
            <div class="controls   ">
              <textarea class=" required paragraph section_field span12" rows="6" placeholder="" name="helpdesk_ticket[custom_field][cf_ma_demande_839887]" id="helpdesk_ticket_custom_field_cf_ma_demande_839887">
</textarea>
            </div> 
                </div>

<div class="control-group ticket_section">
                 <label class=" required control-label cf_civilit_839887-label " for="helpdesk_ticket_cf_civilit_839887">Civilité</label>
            <div class="controls   ">
              <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_civilit_839887]" id="helpdesk_ticket_custom_field_cf_civilit_839887"><option value="">...</option>
<option data-id="15000031273" value="Madame">Madame</option>
<option data-id="15000031274" value="Monsieur">Monsieur</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_nom_839887-label " for="helpdesk_ticket_cf_nom_839887">Nom</label>
            <div class="controls   ">
              <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_nom_839887]" id="helpdesk_ticket_custom_field_cf_nom_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_prnom_839887-label " for="helpdesk_ticket_cf_prnom_839887">Prénom</label>
            <div class="controls   ">
              <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_prnom_839887]" id="helpdesk_ticket_custom_field_cf_prnom_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_activit_839887-label " for="helpdesk_ticket_cf_activit_839887">Activité</label>
            <div class="controls   ">
              <select class="  dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_activit_839887]" id="helpdesk_ticket_custom_field_cf_activit_839887"><option value="">...</option>
<option data-id="15000030717" value="Autre commerçant">Autre commerçant</option>
<option data-id="15000030718" value="Boulanger – Pâtissier">Boulanger – Pâtissier</option>
<option data-id="15000030719" value="Café – Bar">Café – Bar</option>
<option data-id="15000030720" value="Entreprise Prof. Libérale">Entreprise Prof. Libérale</option>
<option data-id="15000030721" value="Restauration rapide">Restauration rapide</option>
<option data-id="15000030722" value="Restauration traditionnelle">Restauration traditionnelle</option>
<option data-id="15000030723" value="Revendeur alimentaire">Revendeur alimentaire</option>
<option data-id="15000030724" value="Traiteur">Traiteur</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_adresse_839887-label " for="helpdesk_ticket_cf_adresse_839887">Adresse</label>
            <div class="controls   ">
              <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_adresse_839887]" id="helpdesk_ticket_custom_field_cf_adresse_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_code_postal_839887-label " for="helpdesk_ticket_cf_code_postal_839887">Code postal</label>
            <div class="controls   ">
              <input class=" required number section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_code_postal_839887]" id="helpdesk_ticket_custom_field_cf_code_postal_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_ville_839887-label " for="helpdesk_ticket_cf_ville_839887">Ville</label>
            <div class="controls   ">
              <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_ville_839887]" id="helpdesk_ticket_custom_field_cf_ville_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_tlphone_839887-label " for="helpdesk_ticket_cf_tlphone_839887">Téléphone</label>
            <div class="controls   ">
              <input class="  text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_tlphone_839887]" id="helpdesk_ticket_custom_field_cf_tlphone_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_fax_839887-label " for="helpdesk_ticket_cf_fax_839887">Fax</label>
            <div class="controls   ">
              <input class="  number section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_fax_839887]" id="helpdesk_ticket_custom_field_cf_fax_839887" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_ma_demande_839887-label " for="helpdesk_ticket_cf_ma_demande_839887">Ma demande</label>
            <div class="controls   ">
              <textarea class=" required paragraph section_field span12" rows="6" placeholder="" name="helpdesk_ticket[custom_field][cf_ma_demande_839887]" id="helpdesk_ticket_custom_field_cf_ma_demande_839887">
</textarea>
            </div> 
                </div>

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