diff --git a/app/controllers/demandes_controller.rb b/app/controllers/demandes_controller.rb
new file mode 100644
index 000000000..53fad026d
--- /dev/null
+++ b/app/controllers/demandes_controller.rb
@@ -0,0 +1,26 @@
+class DemandesController < ApplicationController
+  layout "new_application"
+
+  def new
+  end
+
+  def create
+    PipedriveService.add_demande(
+      demande_params[:email],
+      demande_params[:phone],
+      demande_params[:name],
+      demande_params[:poste],
+      demande_params[:source],
+      demande_params[:organization_name],
+      demande_params[:address]
+    )
+    flash.notice = 'Votre demande a bien été enregistrée, nous vous contacterons rapidement.'
+    redirect_to root_path
+  end
+
+  private
+
+  def demande_params
+    params.permit(:organization_name, :poste, :name, :email, :phone, :source, :address)
+  end
+end
diff --git a/app/lib/pipedrive/api.rb b/app/lib/pipedrive/api.rb
index 0ce970635..8cbf1ca04 100644
--- a/app/lib/pipedrive/api.rb
+++ b/app/lib/pipedrive/api.rb
@@ -2,6 +2,7 @@ class Pipedrive::API
   PIPEDRIVE_ALL_NOT_DELETED_DEALS = 'all_not_deleted'
   PIPEDRIVE_DEALS_URL = [PIPEDRIVE_API_URL, 'deals'].join("/")
   PIPEDRIVE_PEOPLE_URL = [PIPEDRIVE_API_URL, 'persons'].join("/")
+  PIPEDRIVE_ORGANIZATIONS_URL = [PIPEDRIVE_API_URL, 'organizations'].join("/")
 
   def self.get_persons_owned_by_user(user_id)
     url = PIPEDRIVE_PEOPLE_URL
@@ -23,12 +24,24 @@ class Pipedrive::API
     self.put(url, params)
   end
 
+  def self.post_deal(params)
+    self.post(PIPEDRIVE_DEALS_URL, params)
+  end
+
   def self.put_person(person_id, params)
     url = [PIPEDRIVE_PEOPLE_URL, person_id].join("/")
 
     self.put(url, params)
   end
 
+  def self.post_person(params)
+    self.post(PIPEDRIVE_PEOPLE_URL, params)
+  end
+
+  def self.post_organization(params)
+    self.post(PIPEDRIVE_ORGANIZATIONS_URL, params)
+  end
+
   private
 
   def self.get(url, params)
@@ -47,4 +60,10 @@ class Pipedrive::API
 
     RestClient.put(url, params.to_json, { content_type: :json })
   end
+
+  def self.post(url, params)
+    url = "#{url}?api_token=#{PIPEDRIVE_TOKEN}"
+
+    RestClient.post(url, params.to_json, { content_type: :json })
+  end
 end
diff --git a/app/lib/pipedrive/deal_adapter.rb b/app/lib/pipedrive/deal_adapter.rb
index a8c4ad826..1d7f969ca 100644
--- a/app/lib/pipedrive/deal_adapter.rb
+++ b/app/lib/pipedrive/deal_adapter.rb
@@ -33,4 +33,15 @@ class Pipedrive::DealAdapter
 
     Pipedrive::API.put_deal(deal_id, params)
   end
+
+  def self.add_deal(organisation_id, person_id, title)
+    params = {
+      org_id: organisation_id,
+      person_id: person_id,
+      title: title,
+      user_id: Pipedrive::PersonAdapter::PIPEDRIVE_ROBOT_ID
+    }
+
+    Pipedrive::API.post_deal(params)
+  end
 end
diff --git a/app/lib/pipedrive/organization_adapter.rb b/app/lib/pipedrive/organization_adapter.rb
new file mode 100644
index 000000000..b4fb88ea1
--- /dev/null
+++ b/app/lib/pipedrive/organization_adapter.rb
@@ -0,0 +1,13 @@
+class Pipedrive::OrganizationAdapter
+  def self.add_organization(name, address)
+    params = {
+      name: name,
+      owner_id: Pipedrive::PersonAdapter::PIPEDRIVE_ROBOT_ID,
+      address: address
+    }
+
+    response = Pipedrive::API.post_organization(params)
+
+    JSON.parse(response.body)['data']['id']
+  end
+end
diff --git a/app/lib/pipedrive/person_adapter.rb b/app/lib/pipedrive/person_adapter.rb
index f395bbea9..88d6526fd 100644
--- a/app/lib/pipedrive/person_adapter.rb
+++ b/app/lib/pipedrive/person_adapter.rb
@@ -1,5 +1,6 @@
 class Pipedrive::PersonAdapter
   PIPEDRIVE_POSTE_ATTRIBUTE_ID = '33a790746f1713d712fe97bcce9ac1ca6374a4d6'
+  PIPEDRIVE_SOURCE_ATTRIBUTE_ID = '2fa7864f467ffa97721cbcd08df5a3d591b15f50'
   PIPEDRIVE_ROBOT_ID = '2748449'
 
   def self.get_demandes_from_persons_owned_by_robot
@@ -19,4 +20,20 @@ class Pipedrive::PersonAdapter
 
     Pipedrive::API.put_person(person_id, params)
   end
+
+  def self.add_person(email, phone, name, organization_id, poste, source)
+    params = {
+      email: email,
+      phone: phone,
+      name: name,
+      org_id: organization_id,
+      owner_id: PIPEDRIVE_ROBOT_ID,
+      "#{PIPEDRIVE_POSTE_ATTRIBUTE_ID}": poste,
+      "#{PIPEDRIVE_SOURCE_ATTRIBUTE_ID}": source
+    }
+
+    response = Pipedrive::API.post_person(params)
+
+    JSON.parse(response.body)['data']['id']
+  end
 end
diff --git a/app/services/pipedrive_service.rb b/app/services/pipedrive_service.rb
index 09fc32779..f7b7c0875 100644
--- a/app/services/pipedrive_service.rb
+++ b/app/services/pipedrive_service.rb
@@ -14,4 +14,10 @@ class PipedriveService
   def self.get_demandes
     Pipedrive::PersonAdapter.get_demandes_from_persons_owned_by_robot
   end
+
+  def self.add_demande(email, phone, name, poste, source, organization_name, address)
+    organization_id = Pipedrive::OrganizationAdapter.add_organization(organization_name, address)
+    person_id = Pipedrive::PersonAdapter.add_person(email, phone, name, organization_id, poste, source)
+    Pipedrive::DealAdapter.add_deal(organization_id, person_id, organization_name)
+  end
 end
diff --git a/app/views/demandes/new.html.haml b/app/views/demandes/new.html.haml
new file mode 100644
index 000000000..1cf5ae528
--- /dev/null
+++ b/app/views/demandes/new.html.haml
@@ -0,0 +1,43 @@
+.container
+  %h1 Demande de compte administrateur
+  %p Pour obtenir un compte administrateur sur demarches-simplifiees.fr, veuillez remplir le formulaire ci-dessous et un membre de notre équipe vous contactera très prochainement.
+  %p Tous les champs sont obligatoires.
+
+  = form_tag({ controller: 'demandes', action: 'create' }, class: 'form') do
+
+    = label_tag :organization_name do
+      Quel est le nom de votre organisme ?
+      %span.mandatory *
+    = text_field_tag :organization_name, nil, placeholder: 'service jeunesse et prévention, direction des affaires maritimes', required: true
+
+    = label_tag :poste do
+      Quel est votre poste ?
+      %span.mandatory *
+    = text_field_tag :poste, nil, required: true
+
+    = label_tag :name do
+      Quel est votre prénom et votre nom ?
+      %span.mandatory *
+    = text_field_tag :name, nil, required: true
+
+    = label_tag :email do
+      Quelle est l'adresse email pour laquelle vous souhaitez un compte ?
+      %span.mandatory *
+    = email_field_tag :email, nil, required: true
+
+    = label_tag :phone do
+      Quel est votre numéro de téléphone ?
+      %span.mandatory *
+    = text_field_tag :phone, nil, required: true
+
+    = label_tag :source do
+      Comment avez-vous entendu parlé de demarches-simplifiees.fr ?
+      %span.mandatory *
+    = text_field_tag :source, nil, required: true
+
+    = label_tag :address do
+      Quel est le code postal de votre institution ?
+      %span.mandatory *
+    = text_field_tag :address, nil, required: true
+
+    = submit_tag 'Envoyer', class: 'button',  data: { disable_with: "Envoi..."  }
diff --git a/app/views/root/landing.html.haml b/app/views/root/landing.html.haml
index f518b3086..7fd087644 100644
--- a/app/views/root/landing.html.haml
+++ b/app/views/root/landing.html.haml
@@ -67,7 +67,7 @@
           %p.role-panel-explanation Créez des formulaires en ligne en quelques minutes et instruisez les demandes des usagers sur une plateforme dédiée
 
           = link_to "Demander un compte",
-            "https://pipedrivewebforms.com/form/c4a5de08b0a1dcc92374e853aa11905a1871869",
+            new_demande_path,
             class: "role-panel-button-primary",
             target: "_blank",
             rel: "noopener noreferrer",
diff --git a/config/routes.rb b/config/routes.rb
index be4399b44..106e1002d 100644
--- a/config/routes.rb
+++ b/config/routes.rb
@@ -69,6 +69,7 @@ Rails.application.routes.draw do
 
   resources :stats, only: [:index]
   resources :accessibilite, only: [:index]
+  resources :demandes, only: [:new, :create]
 
   namespace :france_connect do
     get 'particulier' => 'particulier#login'