document.write('<form id="form_mohsendavari" action="http://www.beauty4u.ir/saman_portable/payment_saman_start.php" method=post>  <table border="0" width="100%" dir="rtl" cellspacing="0" cellpadding="0" >    <tr>      <td width="100" height="30">نام و نام خانوادگي :</td>      <td><input type="text" name="fullname" size="40" dir="rtl" lang="fa"  /><span class="need">*</span></td>    </tr>	<tr>		<td height="30"> مبلغ:</td>      <td><input type="text" name="price" size="10" dir="ltr"     /> ریال <span class="need">*</span></td>		</tr>	<tr>		<td height="30">توضیجات :</td>      <td><textarea name="note" style="width:300px;height:100px"    ></textarea><span class="need">*</span></td></tr> <tr><td height="30">کد امنيتي :</td>    <td valign="top"><table border="0" width="100%" cellspacing="0" cellpadding="0">		<tr>			<td width="148"><input type="text" name="user_code" size="12" dir="ltr"    /><span class="need"> 			*</span></td><td  width="210"> <img src="http://www.beauty4u.ir/saman_portable/visual-captcha.php" id="sec_code" width="200" height="60" alt="Visual CAPTCHA" /></td><td> <a href="#" onclick="document.getElementById(\'sec_code\').src=\'http://www.beauty4u.ir/saman_portable/visual-captcha.php?time=\'+escape(new Date().getTime())+\'\'" >کد امنیتی جدید</a></td>				</tr>			</table>		</td>	</tr> <tr>    <td height="30">&nbsp;</td>    <td><input type="submit" value="ارسال درخواست" /></td>  </tr></table></form>')