<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
    <meta name="referrer" content="no-referrer-when-downgrade">
    
    
            

    <link href="https://postnl.tfaforms.net/dist/form-builder/5.0.0/wforms-layout.css?v=563ac58609e6d9a3ea68459984d90066b680ad16" rel="stylesheet" type="text/css" />

    <link href="https://postnl.tfaforms.net/uploads/themes/theme-64.css" rel="stylesheet" type="text/css" />
    <link href="https://postnl.tfaforms.net/dist/form-builder/5.0.0/wforms-jsonly.css?v=563ac58609e6d9a3ea68459984d90066b680ad16" rel="alternate stylesheet" title="This stylesheet activated by javascript" type="text/css" />
    
    
    


<div class="wFormContainer" >
    <div class="wFormHeader"></div>
    <style type="text/css">
                #tfa_44,
                *[id^="tfa_44["] {
                    width: 400px !important;
                }
                #tfa_44-D,
                *[id^="tfa_44["][class~="field-container-D"] {
                    width: auto !important;
                }
            
                #tfa_59,
                *[id^="tfa_59["] {
                    width: 400px !important;
                }
                #tfa_59-D,
                *[id^="tfa_59["][class~="field-container-D"] {
                    width: auto !important;
                }
            
                #tfa_63,
                *[id^="tfa_63["] {
                    width: 400px !important;
                }
                #tfa_63-D,
                *[id^="tfa_63["][class~="field-container-D"] {
                    width: auto !important;
                }
            
                #tfa_44,
                *[id^="tfa_44["] {
                    height: 200px !important
                }
                #tfa_44-D,
                *[id^="tfa_44["][class~="field-container-D"] {
                    height: auto !important;
                }
                #tfa_44-L,
                label[id^="tfa_44["],
                *[id^="tfa_44["][id$="-L"] {
                    height: auto !important;
                }
            
                #tfa_59,
                *[id^="tfa_59["] {
                    height: 130px !important
                }
                #tfa_59-D,
                *[id^="tfa_59["][class~="field-container-D"] {
                    height: auto !important;
                }
                #tfa_59-L,
                label[id^="tfa_59["],
                *[id^="tfa_59["][id$="-L"] {
                    height: auto !important;
                }
            
                #tfa_63,
                *[id^="tfa_63["] {
                    height:  !important
                }
                #tfa_63-D,
                *[id^="tfa_63["][class~="field-container-D"] {
                    height: auto !important;
                }
                #tfa_63-L,
                label[id^="tfa_63["],
                *[id^="tfa_63["][id$="-L"] {
                    height: auto !important;
                }
            </style><div class=""><div class="wForm" id="4959973-WRPR" data-language="nl" dir="ltr">
<div class="codesection" id="code-4959973">
</div>
<form method="post" action="https://postnl.tfaforms.net/api_v2/rest/workflow/processor" class="hintsBelow labelsAbove" id="4959973">
<div class="oneField field-container-D    " id="tfa_1-D">
<label id="tfa_1-L" class="label preField reqMark" for="tfa_1">Voornaam:</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_1" name="tfa_1" value="" autocomplete="off" title="Voornaam:" class="validate-alphanum required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_26-D">
<label id="tfa_26-L" class="label preField reqMark" for="tfa_26">Achternaam</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_26" name="tfa_26" value="" autocomplete="off" title="Achternaam" class="validate-alphanum required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_27-D">
<label id="tfa_27-L" class="label preField reqMark" for="tfa_27">Bedrijfsnaam</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_27" name="tfa_27" value="" autocomplete="off" title="Bedrijfsnaam" class="required"></div>
</div>
<div class="oneField field-container-D   hintsBelow " id="tfa_19-D">
<label id="tfa_19-L" class="label preField reqMark" for="tfa_19">Telefoonnummer</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_19" name="tfa_19" value="" autocomplete="off" title="Telefoonnummer" class="validate-integer required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_12-D">
<label id="tfa_12-L" class="label preField reqMark" for="tfa_12">E-mailadres</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_12" name="tfa_12" value="" autocomplete="off" title="E-mailadres" class="validate-email required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_68-D">
<label id="tfa_68-L" class="label preField reqMark" for="tfa_68">Reden voor contact</label><br><div class="inputWrapper"><select aria-required="true" id="tfa_68" name="tfa_68" title="Reden voor contact" class="required"><option value="">Maak een keuze</option>
<option value="tfa_69" id="tfa_69" class="">Offerte aanvragen</option>
<option value="tfa_70" id="tfa_70" class="">Vraag / opmerking</option></select></div>
</div>
<div class="oneField field-container-D    " id="tfa_71-D">
<label id="tfa_71-L" class="label preField reqMark" for="tfa_71">Hoeveel pakketten en/of pallets verstuur je op jaarbasis?</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_71" name="tfa_71" value="" title="Hoeveel pakketten en/of pallets verstuur je op jaarbasis?" class="required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_72-D" role="group" aria-labelledby="tfa_72-L" data-tfa-labelledby="-L tfa_72-L">
<label id="tfa_72-L" class="label preField reqMark" data-tfa-check-label-for="tfa_72" aria-label="Wat is je ontvangerstype?   Verplicht">Wat is je ontvangerstype?</label><br><div class="inputWrapper"><span id="tfa_72" class="choices vertical required"><span class="oneChoice"><input type="checkbox" value="tfa_73" class="calc-bTybe calcval-1" id="tfa_73" name="tfa_73" aria-labelledby="tfa_73-L" data-tfa-labelledby="tfa_72-L tfa_73-L" data-tfa-parent-id="tfa_72"><label class="label postField" id="tfa_73-L" for="tfa_73"><span class="input-checkbox-faux"></span>Particulier</label></span><span class="oneChoice"><input type="checkbox" value="tfa_74" class="calc-bTybe calcval-1" id="tfa_74" name="tfa_74" aria-labelledby="tfa_74-L" data-tfa-labelledby="tfa_72-L tfa_74-L" data-tfa-parent-id="tfa_72"><label class="label postField" id="tfa_74-L" for="tfa_74"><span class="input-checkbox-faux"></span>Zakelijk&nbsp;</label></span></span></div>
</div>
<div class="oneField field-container-D    " id="tfa_78-D" role="group" aria-labelledby="tfa_78-L" data-tfa-labelledby="-L tfa_78-L">
<label id="tfa_78-L" class="label preField reqMark" data-tfa-check-label-for="tfa_78" aria-label="Onder welke condities wil je je producten verzenden? (Meerdere opties mogelijk)   Verplicht">Onder welke condities wil je je producten verzenden? (Meerdere opties mogelijk)</label><br><div class="inputWrapper"><span id="tfa_78" class="choices vertical required"><span class="oneChoice"><input type="checkbox" value="tfa_79" class="" id="tfa_79" name="tfa_79" aria-labelledby="tfa_79-L" data-tfa-labelledby="tfa_78-L tfa_79-L" data-tfa-parent-id="tfa_78"><label class="label postField" id="tfa_79-L" for="tfa_79"><span class="input-checkbox-faux"></span>Geen specifieke condities</label></span><span class="oneChoice"><input type="checkbox" value="tfa_80" class="" id="tfa_80" name="tfa_80" aria-labelledby="tfa_80-L" data-tfa-labelledby="tfa_78-L tfa_80-L" data-tfa-parent-id="tfa_78"><label class="label postField" id="tfa_80-L" for="tfa_80"><span class="input-checkbox-faux"></span>2-8 graden</label></span><span class="oneChoice"><input type="checkbox" value="tfa_81" class="" id="tfa_81" name="tfa_81" aria-labelledby="tfa_81-L" data-tfa-labelledby="tfa_78-L tfa_81-L" data-tfa-parent-id="tfa_78"><label class="label postField" id="tfa_81-L" for="tfa_81"><span class="input-checkbox-faux"></span>15-25 graden</label></span></span></div>
</div>
<div class="oneField field-container-D   hintsBelow " id="tfa_44-D">
<label id="tfa_44-L" class="label preField reqMark" for="tfa_44">Vertel hier meer over je type zendingen of je wensen</label><br><div class="inputWrapper"><textarea aria-required="true" maxlength="250" id="tfa_44" name="tfa_44" title="Vertel hier meer over je type zendingen of je wensen" class="required"></textarea></div>
</div>
<div class="oneField field-container-D    " id="tfa_83-D" role="radiogroup" aria-labelledby="tfa_83-L" data-tfa-labelledby="-L tfa_83-L">
<label id="tfa_83-L" class="label preField reqMark" data-tfa-check-label-for="tfa_83">Ik geef toestemming voor het gebruik van mijn gegevens voor gepersonaliseerde communicatie.</label><br><div class="inputWrapper"><span id="tfa_83" class="choices vertical required"><span class="oneChoice"><input type="radio" value="tfa_84" class="" id="tfa_84" name="tfa_83" aria-required="true" aria-labelledby="tfa_84-L" data-tfa-labelledby="tfa_83-L tfa_84-L" data-tfa-parent-id="tfa_83"><label class="label postField" id="tfa_84-L" for="tfa_84"><span class="input-radio-faux"></span>Ja</label></span><span class="oneChoice"><input type="radio" value="tfa_85" class="" id="tfa_85" name="tfa_83" aria-required="true" aria-labelledby="tfa_85-L" data-tfa-labelledby="tfa_83-L tfa_85-L" data-tfa-parent-id="tfa_83"><label class="label postField" id="tfa_85-L" for="tfa_85"><span class="input-radio-faux"></span>Nee</label></span></span></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_49-D">
<label id="tfa_49-L" class="label preField reqMark" for="tfa_49">Taal</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_49" name="tfa_49" value="nl_NL" default="nl_NL" maxlength="50" title="Taal" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_59-D">
<label id="tfa_59-L" class="label preField " for="tfa_59">E-mail tekst</label><br><div class="inputWrapper"><textarea maxlength="300" id="tfa_59" name="tfa_59" title="E-mail tekst" class=""></textarea></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_51-D">
<label id="tfa_51-L" class="label preField reqMark" for="tfa_51">Categorie</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_51" name="tfa_51" value="contact opnemen" default="contact opnemen" maxlength="50" title="Categorie" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_61-D">
<label id="tfa_61-L" class="label preField reqMark" for="tfa_61">Record Type ID</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_61" name="tfa_61" value="0120J000000opbSQAQ" default="0120J000000opbSQAQ" title="Record Type ID" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_65-D">
<label id="tfa_65-L" class="label preField reqMark" for="tfa_65">Formulier_titel</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_65" name="tfa_65" value="Contact farmaceutisch pakket" default="Contact farmaceutisch pakket" title="Formulier_titel" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_63-D">
<label id="tfa_63-L" class="label preField " for="tfa_63">Subjectline bevestigingsmail (bij leeg veld wordt default Marketing Cloud waarde gebruikt)</label><br><div class="inputWrapper"><textarea maxlength="300" id="tfa_63" name="tfa_63" title="Subjectline bevestigingsmail (bij leeg veld wordt default Marketing Cloud waarde gebruikt)" class=""></textarea></div>
</div>
<input type="hidden" id="tfa_82" name="tfa_82" value="" class="formula=bType"><div class="actions" id="4959973-A" data-contentid="submit_button"><input type="submit" data-label="Verzenden" class="primaryAction" id="submit_button" value="Verzenden"></div>
<div style="clear:both"></div>
<input type="hidden" value="260-54031b477c7e621820412c8a3d747b79" name="tfa_dbCounters" id="tfa_dbCounters" autocomplete="off"><input type="hidden" value="4959973" name="tfa_dbFormId" id="tfa_dbFormId"><input type="hidden" value="" name="tfa_dbResponseId" id="tfa_dbResponseId"><input type="hidden" value="591c0e227a19e57c1a9366948ea103eb" name="tfa_dbControl" id="tfa_dbControl"><input type="hidden" value="" name="tfa_dbWorkflowSessionUuid" id="tfa_dbWorkflowSessionUuid"><input type="hidden" value="1745618527" name="tfa_dbTimeStarted" id="tfa_dbTimeStarted" autocomplete="off"><input type="hidden" value="12" name="tfa_dbVersionId" id="tfa_dbVersionId"><input type="hidden" value="" name="tfa_switchedoff" id="tfa_switchedoff">
</form>
</div></div><div class="wFormFooter"><p class="supportInfo"><br></p></div>
  <p class="supportInfo" >
      </p>
 </div>

Farmaceutisch pakket                                                                                

Neem contact met ons op

PostNL Pharma & Care 

be - privacyverklaring

be - alles over cookies (cookieverklaring)

be - gebruiksvoorwaarden

be - algemene voorwaarden

Direct regelen

be - service & contact

Hulp

© PostNL

PostNL Pharma & Care

Verzenden

Ontvangen

Zakelijke oplossingen

Over PostNL

Direct regelen

PostNL-app

Hulp