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<div class="wFormContainer" >
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    <style type="text/css">
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<div class="codesection" id="code-4960084">
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<div class="oneField field-container-D    " id="tfa_68-D">
<label id="tfa_68-L" class="label preField reqMark" for="tfa_68">Sujet</label><br><div class="inputWrapper"><select aria-required="true" id="tfa_68" name="tfa_68" title="Sujet" class="required"><option value="">Veuillez sélectionner</option>
<option value="tfa_69" id="tfa_69" class="">Demander un devis</option>
<option value="tfa_70" id="tfa_70" class="">Demande / Remarque</option></select></div>
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<div class="oneField field-container-D    " id="tfa_1-D">
<label id="tfa_1-L" class="label preField reqMark" for="tfa_1">Prénom</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_1" name="tfa_1" value="" autocomplete="off" title="Prénom" class="validate-alphanum required"></div>
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<div class="oneField field-container-D    " id="tfa_26-D">
<label id="tfa_26-L" class="label preField reqMark" for="tfa_26">Nom</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_26" name="tfa_26" value="" autocomplete="off" title="Nom" class="validate-alphanum required"></div>
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<div class="oneField field-container-D    " id="tfa_27-D">
<label id="tfa_27-L" class="label preField reqMark" for="tfa_27">Nom de la société</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_27" name="tfa_27" value="" autocomplete="off" title="Nom de la société" class="required"></div>
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<div class="oneField field-container-D   hintsBelow " id="tfa_19-D">
<label id="tfa_19-L" class="label preField reqMark" for="tfa_19">Numéro de téléphone</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_19" name="tfa_19" value="" autocomplete="off" title="Numéro de téléphone" class="validate-integer required"></div>
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<div class="oneField field-container-D    " id="tfa_12-D">
<label id="tfa_12-L" class="label preField reqMark" for="tfa_12">Adresse e-mail</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_12" name="tfa_12" value="" autocomplete="off" title="Adresse e-mail" class="validate-email required"></div>
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<div class="oneField field-container-D   hintsBelow " id="tfa_44-D">
<label id="tfa_44-L" class="label preField reqMark" for="tfa_44">Ma question</label><br><div class="inputWrapper"><textarea aria-required="true" maxlength="300" id="tfa_44" name="tfa_44" title="Ma question" class="required"></textarea></div>
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<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="fr_BE" default="fr_BE" maxlength="50" title="Taal" class="required"></div>
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<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>
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<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>
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<div class="oneField field-container-D     wf-acl-hidden" id="tfa_53-D">
<label id="tfa_53-L" class="label preField reqMark" for="tfa_53">Webform Source</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_53" name="tfa_53" value="pharma contact be" default="pharma contact be" title="Webform Source" class="required"></div>
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<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 express service" default="Contact express service" title="Formulier_titel" class="required"></div>
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<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>
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<div class="actions" id="4960084-A" data-contentid="submit_button"><input type="submit" data-label="Envoyer" class="primaryAction" id="submit_button" value="Envoyer"></div>
<div style="clear:both"></div>
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</div></div><div class="wFormFooter"><p class="supportInfo"><br></p></div>
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