< form action = "https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8" method = "POST" >
< input type = "hidden" name = "orgid" value = "00D6g000006wOuu" >
< input type = "hidden" name = "retURL" value = "http://saafon.org/about-us/confirm/" >
< h3 > Farmer Support Request < /h3>
To request assistance, please use this web – to –
case form to submit a Farmer Support request.

Please fill out the form below and one of our state coordinators will be in touch soon.

Fields marked with an * are required

Please provide your contact information.

< label for = "name" > First and Last Name*: < input id = "name" maxlength = "80" name = "name" size = "20" type = "text" required = "true" >

< label for = "email" > Email *: < /label>

< label for = "phone" > Phone *: < /label>

Farm or Company Name,
if applicable: < input id = "00N6g00000RdAv7" maxlength = "100" name = "00N6g00000RdAv7" size = "20" type = "text" >

Please provide a short title about your issue / need.

< label for = "subject" > Subject *: < /label>

Provide more details about your issue / need in the descriptions field below.

< label for = "description" > Description *: < /label> < textarea name = "description" required = "true" > < /textarea>

Click the Submit Query button to submit your request

< input type = "submit" name = "submit" >

< /form>