<form data-dojo-attach-point="containerNode" data-dojo-attach-event="onreset:_onReset,onsubmit:_onSubmit" name="FeedbackForm" lang="en" action="https://www.lufthansa.com/online/portal/lh/de/help_contact/feedback/!ut/p/c5/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hHg2B_U3d350DfMA9jA0czF5OgUFNLC9MAU6B8JE75gAADYnQb4ACOhHR76Uel5-QnAV0ZDnI3bne4mOKXB7kTJI_HJX4e-bmp-gW5oRGVwZ66AI5DSgQ!/dl3/d3/L0lJSklna2tra2tra25wQSEvb013d0FBQVlnQUNFSVFRaUtVUXhnb1lCem5KUUZnQSEvNEJuNHNvMFZnTGE5Mmd6a0xLQnl3ZyEhLzZfQTBTTzVHR0NRTVZIMzBBNkQ0UlU1OTg1UDUvN19BMFNPNUdHQ1FNVkgzMEE2RDRSVTU5MEkwMS9zYS5GZWVkYmFja0lucHV0QWN0aW9uL25vcm1hbC9EZWZhdWx0/?l=en&cid=18002&action=FeedbackInputAction&command=sumbitForm&p=LH&s=DE&l=en&cid=18002&action=FeedbackInputAction&command=sumbitForm&p=LH&s=DE" id="fb_form" method="post" widgetid="fb_form">
<!-- Hidden input to disable content header portlet-->
<input type="hidden" name="formSubmitted" value="true">
<input type="hidden" value="" name="formtype" id="formTypeInput">
<input type="hidden" name="isFlynet" value="false">
<input type="hidden" name="categoryId" id="categoryId" value="">
<div id="fb_mod_personal" class="lh_fbMargin clearfix">
<div class="fieldwrapper wide">
<h1>Your personal data</h1>
</div>
<span class="overwriteMessage">Please note that any changes will not be saved to your profile.</span>
<div class="subtpl">
<div class="fieldwrapper">
<label for="title" class="title">Title</label>
<div id="title"><table class="dijit dijitReset dijitInline dijitLeft dijitDownArrowButton fb_protect title dijitSelect dijitValidationTextBox dijitSelectIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" data-dojo-attach-point="_buttonNode,tableNode,focusNode,_popupStateNode" cellspacing="0" cellpadding="0" role="listbox" aria-haspopup="true" tabindex="0" id="lh_widget_form_KeySelect_0" aria-required="true" widgetid="lh_widget_form_KeySelect_0" aria-expanded="false" aria-invalid="true" style="-webkit-user-select: none;"><tbody role="presentation"><tr role="presentation"><td class="dijitReset dijitStretch dijitButtonContents" role="presentation"><div class="dijitReset dijitInputField dijitButtonText" data-dojo-attach-point="containerNode,textDirNode" role="presentation"><span role="option" class="dijitReset dijitInline dijitSelectLabel dijitValidationTextBoxLabel ">Please select</span></div><div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><input type="hidden" name="Salutation_1" data-dojo-attach-point="valueNode" value=" " aria-hidden="true"></td><td class="dijitReset dijitRight dijitButtonNode dijitArrowButton dijitDownArrowButton dijitArrowButtonContainer" data-dojo-attach-point="titleNode" role="presentation"><input class="dijitReset dijitInputField dijitArrowButtonInner" value="▼ " type="text" tabindex="-1" readonly="readonly" role="presentation"></td></tr></tbody></table></div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="firstname" class="firstname">First name</label>
<div id="firstname"><div class="dijit dijitReset dijitInline dijitLeft fb_protect firstname dijitTextBox dijitValidationTextBox dijitTextBoxError dijitValidationTextBoxError dijitError" id="widget_firstname" role="presentation" widgetid="firstname"><div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" name="FirstName_1" type="text" tabindex="0" id="firstname" aria-required="true" maxlength="50" value="" aria-invalid="true"></div></div></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="lastname" class="lastname">Last name</label>
<div id="lastname"><div class="dijit dijitReset dijitInline dijitLeft fb_protect lastname dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_lastname" role="presentation" widgetid="lastname"><div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" name="LastName_1" type="text" tabindex="0" id="lastname" aria-required="true" maxlength="50" value="" aria-invalid="false"></div></div></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="email" class="email">Email</label>
<div id="email"><div class="dijit dijitReset dijitInline dijitLeft fb_protect email dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete dijitTextBoxFocused dijitValidationTextBoxFocused dijitTextBoxIncompleteFocused dijitValidationTextBoxIncompleteFocused dijitIncompleteFocused dijitFocused" id="widget_email" role="presentation" widgetid="email"><div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" name="Email_1" type="text" tabindex="0" id="email" aria-required="true" value="" aria-invalid="false"></div></div></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="r_email" class="email">Re-enter email</label>
<div id="r_email"><div class="dijit dijitReset dijitInline dijitLeft dijitTextBox dijitValidationTextBox fb_protect email" id="widget_r_email" role="presentation" widgetid="r_email"><div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" name="rEmail_1" type="text" tabindex="0" id="r_email" aria-required="true" value="" aria-invalid="false"></div></div></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="mam_number" class="mam_number">Miles & More number <span class="optional"><span> </span>optional</span></label>
<div id="mam_number"><div class="dijit dijitReset dijitInline dijitLeft dijitTextBox dijitValidationTextBox fb_protect mam_number" id="widget_mam_number" role="presentation" widgetid="mam_number"><div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" name="MamNumber_1" type="text" tabindex="0" id="mam_number" maxlength="15" value="" aria-invalid="false"></div></div></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_catSelector" class="lh_fbMargin clearfix">
<div class="subtpl">
<div class="cl w50 firstColumn">
<h1>What can we do for you?</h1>
<table class="dijit dijitReset dijitInline dijitLeft dijitDownArrowButton fb_protect cat_select1 dijitSelectFixedWidth dijitValidationTextBoxFixedWidth dijitSelect dijitValidationTextBox dijitSelectIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" data-dojo-attach-point="_buttonNode,tableNode,focusNode,_popupStateNode" cellspacing="0" cellpadding="0" role="listbox" aria-haspopup="true" tabindex="0" id="CAT_SELECT_1" aria-required="true" widgetid="CAT_SELECT_1" aria-expanded="false" aria-invalid="true" style="-webkit-user-select: none; display: block; width: auto; font-size: 14px; padding: 1px 0px 1px 10px; margin: 10px 0px 0px;"><tbody role="presentation"><tr role="presentation"><td class="dijitReset dijitStretch dijitButtonContents" role="presentation"><div class="dijitReset dijitInputField dijitButtonText" data-dojo-attach-point="containerNode,textDirNode" role="presentation"><span role="option" class="dijitReset dijitInline dijitSelectLabel dijitValidationTextBoxLabel ">Please select a category</span></div><div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><input type="hidden" name="Category_1" data-dojo-attach-point="valueNode" value=" " aria-hidden="true"></td><td class="dijitReset dijitRight dijitButtonNode dijitArrowButton dijitDownArrowButton dijitArrowButtonContainer" data-dojo-attach-point="titleNode" role="presentation"><input class="dijitReset dijitInputField dijitArrowButtonInner" value="▼ " type="text" tabindex="-1" readonly="readonly" role="presentation"></td></tr></tbody></table></div>
<div class="cr w50 secondColumn">
<p class="x-hidden">
<iframe src="" id="iInterceptor"></iframe>
</p>
</div>
</div>
<div class="selectorQuestion fb_borderSeperator x-hidden clear"></div>
</div>
<div id="fb_mod_dynamicWrapper" class="lh_fbMargin x-hidden">
<h1>Please fill in more detailed information</h1>
<div id="fb_mod_cstm_wrp" class="fb_borderSeperator x-hidden">
<div id="fb_mod_address" class="x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Your address</h3>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="street_name" class="street_name">Street name</label>
<div id="street_name"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="street_no" class="street_no">Number</label>
<div id="street_no"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="zip" class="zip">ZIP</label>
<div id="zip"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="city" class="city">City</label>
<div id="city"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="fieldwrapper">
<label for="address_details" class="addressDetails">Additional address line <span class="optional"><span> </span>optional</span></label>
<div id="address_details"></div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="country" class="country">Country</label>
<div id="country"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper x-hidden">
<label for="regions" class="regions">State / Region</label>
<div id="regions"> </div>
</div>
</div>
</div>
</div>
<div id="fb_mod_phone" class="x-hidden">
<div class="subtpl clear">
<label for="phone" class="phone">Telephone</label>
<div class="cl">
<div class="fieldwrapper wide">
<div id="phone_country"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper wide">
<div id="phone_area"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper wide">
<div id="phone_number"></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_customer2" class="x-hidden fb_borderSeperator">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Personal data of customer <a href="#" id="passenger2" class="fb_removePassenger"><span>Remove</span></a></h3>
</div>
<div class="subtpl">
<div class="fieldwrapper">
<div id="adressChkBox2">
<label for="adressCheckbox2" class="customerChk">Copy address above</label>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="fieldwrapper">
<label for="title2" class="title">Title</label>
<div id="title2"></div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="firstname2" class="firstname">First name</label>
<div id="firstname2"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="lastname2" class="lastname">Last name</label>
<div id="lastname2"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="email2" class="email">Email</label>
<div id="email2"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="r_email2" class="email">Re-enter email</label>
<div id="r_email2"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="mam_number2" class="mam_number">Miles & More number</label>
<div id="mam_number2"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="street_name2" class="street_name">Street name</label>
<div id="street_name2"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="street_no2" class="street_no">Number</label>
<div id="street_no2"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="zip2" class="zip">ZIP</label>
<div id="zip2"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="city2" class="city">City</label>
<div id="city2"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="fieldwrapper">
<label for="address_details2" class="addressDetails">Additional address line</label>
<div id="address_details2"></div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="country2" class="country">Country</label>
<div id="country2"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper x-hidden">
<label for="regions2">State / Region</label>
<div id="regions2"> </div>
</div>
</div>
</div>
<div class="subtpl clear">
<label for="phone2" class="phone">Telephone</label>
<div class="cl">
<div class="fieldwrapper">
<div id="phone_country2" class="cl"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<div id="phone_area2"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<div id="phone_number2" class="cl"></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_customer3" class="x-hidden fb_borderSeperator">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Personal data of customer <a href="#" id="passenger3" class="fb_removePassenger"><span>Remove</span></a></h3>
</div>
<div class="subtpl">
<div class="fieldwrapper">
<div id="adressChkBox3">
<label for="adressCheckbox3" class="customerChk">Copy address above</label>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="fieldwrapper">
<label for="title3" class="title">Title</label>
<div id="title3"></div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="firstname3" class="firstname">First name</label>
<div id="firstname3"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="lastname3" class="lastname">Last name</label>
<div id="lastname3"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="email3" class="email">Email</label>
<div id="email3"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="r_email3" class="email">Re-enter email</label>
<div id="r_email3"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="mam_number3" class="mam_number">Miles & More number</label>
<div id="mam_number3"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="street_name3" class="street_name">Street name</label>
<div id="street_name3"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="street_no3" class="street_no">Number</label>
<div id="street_no3"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="zip3" class="zip">ZIP</label>
<div id="zip3"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="city3" class="city">City</label>
<div id="city3"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="fieldwrapper">
<label for="address_details3" class="addressDetails">Additional address line</label>
<div id="address_details3"></div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="country3" class="country">Country</label>
<div id="country3"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper x-hidden">
<label for="regions3">State / Region</label>
<div id="regions3"> </div>
</div>
</div>
</div>
<div class="subtpl clear">
<label for="phone3" class="phone">Telephone</label>
<div class="cl">
<div class="fieldwrapper">
<div id="phone_country3" class="cl"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<div id="phone_area3"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<div id="phone_number3" class="cl"></div>
</div>
</div>
</div>
</div>
<div id="addCustomer"></div>
</div>
<div id="fb_mod_prm">
<div id="fb_mod_flightDetails" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Flight information</h3>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="fd_file_key">File key</label>
<div id="fd_FileKey"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="fd_flight_number" class="flight_number">Flight number</label> <span class="flight_number_prefix">LH</span>
<div id="fd_FlightNumber"></div>
</div>
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper wide">
<label for="fd_flight_date">Flight date</label>
<div id="fd_flight_date">
<input type="text" id="FlightDate2" name="FlightDate2" class="fb_protect datepicker" widgetid="FlightDate2">
<input type="hidden" id="FlightDateHidden2" name="FlightDateHidden2" disabled="">
</div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper wide">
<label for="fd_flight_time">Flight time</label>
<div id="fd_FlightTime"></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_assistanceType" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Please choose the appropriate option</h3>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<div id="at_LongDistances"></div>
<label for="at_long_distances_radio" class="fb_radio">I cannot walk long distances, however, short distances and stairs are no problem</label>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<div id="at_Staircases"></div>
<label for="at_staircases_radio" class="fb_radio">I can walk short and long distances, but I have difficulties with stairs</label>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper wide">
<div id="at_Walking"></div>
<label for="at_walking_radio" class="fb_radio">I cannot walk at all</label>
</div>
</div>
</div>
</div>
<div id="fb_mod_disabilityType" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<div id="dt_Blind"></div>
<label for="dt_blind_chkbox" class="fb_radio">I am blind or have a severe visual impairment.</label>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<div id="dt_Deaf"></div>
<label for="dt_deaf_chkbox" class="fb_radio">I am deaf or have a severe hearing impairment</label>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper wide">
<div id="dt_Dpna"></div>
<label for="dt_dpna_chkbox" class="fb_radio">I need help finding my way around</label>
</div>
</div>
</div>
</div>
<div id="fb_mod_companionReasons" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<div id="cr_Hc"></div>
<label for="cr_hc_radio" class="fb_radio">I have to travel with an especially trained dog due to my handicap</label>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper wide">
<div id="cr_Pr"></div>
<label for="cr_pr_radio" class="fb_radio">I need to travel in companionship of a dog due to psychological reasons</label>
</div>
</div>
</div>
</div>
<div class="subtpl">
<div class="cr">
<div id="fd_reset" class="x-hidden"></div>
</div>
</div>
</div>
<div id="fb_mod_pir" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Property Irregularity Report Number (PIR)</h3>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper wide">
<label for="pir">PIR number / File Reference (e.g. FRALH12345)</label>
<div id="pir"></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_flight" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Flight information<span class="optional"><span> </span>optional</span></h3>
</div>
<div class="subtpl">
<div class="fieldwrapper">
<label for="FlightDate" class="flightDate">Flight date</label>
<input type="text" id="FlightDate" name="FlightDate" class="fb_protect datepicker" widgetid="FlightDate">
<input type="hidden" id="FlightDateHidden" name="FlightDateHidden" disabled="">
</div>
</div>
<div class="subtpl clear">
<div class="cl">
<div class="fieldwrapper">
<label for="airline" class="airline">Airline</label>
<div id="airline"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="flight_number" class="flight_number">Flight number</label> <span class="flight_number_prefix"></span>
<div id="flight_number"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="fieldwrapper">
<label for="seat_number" class="seat_number">Seat number</label>
<div id="seat_number"></div>
</div>
</div>
<div class="subtpl clear">
<div class="fieldwrapper wide aa-link">
<label for="f-originName0" class="origin">Origin</label>
<input type="text" id="f-originName0" name="originName">
<input type="hidden" id="f-originCode0" name="originCode">
<a href="#" id="lnk-origin" data-dojo-type="lh.widget.AirportAtlas" data-dojo-props="fieldId:'f-originName0',hiddenFieldId:'f-originCode0',url:'/dlvutils/AirportAtlasApplication?app=FB&selected=DE&lang=en',serviceUrl:'/dlvutils/AirportAtlasApplication', app:'FB', language:'en'">
<span class="airport-dir"> </span>
</a>
<div id="lh-typeahead-append-node-f-origin0" class="dijitMenu" tabindex="-1" style="display:none;">
<div id="lh-typeahead-close-f-origin0" class="dijitMenuCloseButton">close</div></div>
<div id="lh-airport-f-origin0" style="display:none;"></div>
</div>
</div>
<div class="subtpl clear">
<div class="fieldwrapper wide aa-link">
<label for="f-destinationName0">Destination</label>
<input type="text" id="f-destinationName0" name="destinationName">
<input type="hidden" id="f-destinationCode0" name="destinationCode">
<a href="#" id="lnk-destination" data-dojo-type="lh.widget.AirportAtlas" data-dojo-props="fieldId:'f-destinationName0',hiddenFieldId:'f-destinationCode0',url:'/dlvutils/AirportAtlasApplication?app=FB&lang=en',serviceUrl:'/dlvutils/AirportAtlasApplication', app:'FB', language:'en'">
<span class="airport-dir"> </span>
</a>
<div id="lh-typeahead-append-node-f-destination0" class="dijitMenu" tabindex="-1" style="display:none;">
<div id="lh-typeahead-close-f-destination0" class="dijitMenuCloseButton">close</div></div>
<div id="lh-airport-f-destination" style="display:none;"></div>
</div>
</div>
</div>
<div id="fb_mod_ticket" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Ticket / booking information<a class="infoMessage" title="Information" id="ticket_toolTip1" href="javascript:void(0);"> </a></h3>
</div>
<div connectid="ticket_toolTip1" dojotype="dijit.Tooltip" showdelay="250" label="Please enter your ticketnumber (s. ticket) or the booking code / filekey from your booking confirmation" class="dijitTooltipData" id="dijit_Tooltip_3" lang="en" widgetid="dijit_Tooltip_3"> </div>
<div class="fbRadioWrapper">
<div class="fieldwrapper wide">
<label for="ticket_no" class="marginLeft">Ticket number</label>
<div id="ticket_no"></div>
</div>
</div>
<div class="fbRadioWrapper">
<div class="fieldwrapper wide">
<label for="file_key" class="marginLeft">File key</label>
<div id="file_key"></div>
</div>
</div>
</div>
<div id="fb_mod_refund" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Refund <a class="infoMessage" title="Information" id="ticket_toolTip1" href="javascript:void(0);"> </a></h3>
<div connectid="ticket_toolTip1" dojotype="dijit.Tooltip" showdelay="250" label="Please enter your details" class="dijitTooltipData" id="dijit_Tooltip_4" lang="en" widgetid="dijit_Tooltip_4"> </div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<div id="refundTicketChkbox">
<label for="refundTicketCheckbox" class="customerChk">Refund entire ticket</label>
</div>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="refund_reason">Refund reason</label>
<div id="refund_reason"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper wide">
<label for="refund_filey_key" class="refund_file_key">File key <span class="optional"><span> </span>optional</span></label>
<div id="refund_file_key"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper wide">
<label for="ticket_no_lh" class="ticket_no_lh">Ticket number</label>
<span class="ticket_number_prefix">220</span><div id="ticket_no_lh"></div>
</div>
</div>
</div>
<div class="subtpl x-hidden">
<div class="cl">
<div class="fieldwrapper wide">
<label for="refund_segment">Travel segments to be refunded</label>
<div id="refund_segment"></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_bank" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Bank account information<a class="infoMessage" id="bank_toolTip1" href="javascript:void(0);"> </a></h3>
<div connectid="bank_toolTip1" dojotype="dijit.Tooltip" showdelay="250" label="Please enter your bank account information" class="dijitTooltipData" id="dijit_Tooltip_5" lang="en" widgetid="dijit_Tooltip_5"> </div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper">
<label for="card_holder">Account holder</label>
<div id="card_holder"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper">
<label for="bank_name">Bank name</label>
<div id="bank_name"></div>
</div>
</div>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper wide">
<label for="iban">IBAN Number</label>
<div id="iban"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper wide">
<label for="bic">SWIFT/BIC code</label>
<div id="bic"></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_technial" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Technical information</h3>
</div>
<div class="subtpl">
<div class="cl">
<div class="fieldwrapper wide">
<label for="browser">Browser name</label>
<div id="browser"></div>
</div>
</div>
<div class="cl">
<div class="fieldwrapper wide">
<label for="os">Operating system</label>
<div id="os"></div>
</div>
</div>
</div>
</div>
<div id="fb_mod_feedbackID" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Feedback ID</h3>
</div>
<div class="subtpl">
<div class="fieldwrapper wide">
<label for="feedbackId">Please enter your feedback ID</label>
<div id="feedbackId"></div>
</div>
</div>
</div>
<div id="fb_mod_comment" class="lh_fbMargin fb_borderSeperator x-hidden">
<div class="fieldwrapper wide">
<h3 class="pi_containerSubline">Your feedback or question</h3>
</div>
<div class="fieldwrapper wide">
<div id="comment"></div>
</div>
</div>
</div>
<input type="hidden" class="x-fup-hd-filename" name="FileName_1" id="attach_filename_1" value="">
<input type="hidden" class="x-fup-hd-filename" name="FileName_2" id="attach_filename_2" value="">
<input type="hidden" class="x-fup-hd-filename" name="FileName_3" id="attach_filename_3" value="">
<input type="hidden" class="x-fup-hd-filename" name="FileName_4" id="attach_filename_4" value="">
<input type="hidden" class="x-fup-hd-filename" name="FileName_5" id="attach_filename_5" value="">
<input type="hidden" class="x-fup-hd-filename" name="FileName_6" id="attach_filename_6" value=""> <br>
<input type="hidden" class="x-fup-hd-fileid" name="FileId_1" id="attach_fileid_1" value="">
<input type="hidden" class="x-fup-hd-fileid" name="FileId_2" id="attach_fileid_2" value="">
<input type="hidden" class="x-fup-hd-fileid" name="FileId_3" id="attach_fileid_3" value="">
<input type="hidden" class="x-fup-hd-fileid" name="FileId_4" id="attach_fileid_4" value="">
<input type="hidden" class="x-fup-hd-fileid" name="FileId_5" id="attach_fileid_5" value="">
<input type="hidden" class="x-fup-hd-fileid" name="FileId_6" id="attach_fileid_6" value="">
</form>
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