document.write('<img src="https://www.formnut.com/inc/print_sec_img.php?sum=FRmJjwlpSj8NOzqafzoLwr/fGpkZArCJh4iIQ11BLoM=" width="150" height="40" border="1" alt="Security image"><br>');
document.write('Please type in the security number displayed above: <input type="text" size="7" name="secnumber" maxlength="5"><input type="hidden" name="checksum" value="FRmJjwlpSj8NOzqafzoLwr/fGpkZArCJh4iIQ11BLoM=">');