document.write('<style type="text/css" media="screen">\
<!--\
#form2mail_5453\
{\
width: 600;\
font-size: 13px;\
font-family: Verdana;\
text-align: left;\
}\
//-->\
</style>\
<form id="form_5453" method="post" action="http://www.i-services.com/membres/formmail/formmail_secur.php?uid=143316&amp;sid=119739&amp;idform=5453" enctype="multipart/form-data" onsubmit=\"return verifier_5453();\">\
<input type="hidden" name="_mail_priority" value="Normal">\
<input type="hidden" name="_mail_subject" value="">\
<input type="hidden" name="_conform_copy" value="">\
<table id="form2mail_5453" cellpadding="10" cellspacing="5">\
<tr>\
<td>Nous &eacute;crire :</td>\
<td><input type=\"text\" name=\"champ_2731\" value=\"\" onclick=\"javascript:if(this.value == \'\') this.value = \'\';\" onfocus=\"javascript:if(this.value == \'\') this.value = \'\';\" onblur=\"javascript:if(this.value == \'\') this.value = \'\';\" style=\"width: 300px;\" /></td>\
</tr>\
<tr>\
<td>Recopiez le code ci-contre <span style="color: #c00;">*</span> :</td>\
<td><img src="http://www.i-services.com/membres/modules/img_rand.php?uid=143316&sid=119739&service=Q" border="0" align="absmiddle" /> <input type="text" name="code_check" size="10" maxlength="5" value="" autocomplete="off" /></td>\
</tr>\
<tr>\
<td colspan="2" align="center"><input name="bouton" type="submit" value="Valider" /></td>\
</tr>\
</table>\
</form>\
');