document.write( "<img src=\"http://www.mortgagewizardsinc.com/captcha/captcha_cache/captcha_d26657847b8ae144efa2058056c42d8e.png\" alt=\"[image] Please enter code as shown in graphic.\" border=\"1\"><br>" );
document.write( "<input type=\"hidden\" name=\"captchaImg\" value=\"d26657847b8ae144efa2058056c42d8e\"><br>" );
document.write( "<label><b>Confirmation Code: </b><input type=\"text\" name=\"captchaAttempt\"></label>" );