<form action="{ACTION}" method="get" enctype="{ENCODING}" target="{TARGET}">
  <p> 
    <label for="scan_host">IP/Host: </label>
    <input type="text" id="scan_host" name="scan_host" size="30">
  </p>
  <p> 
    <input type="checkbox" name="scan_ftp" value="YES">-FTP 
    <input type="checkbox" name="scan_telnet" value="YES">-Telnet 
    <input type="checkbox" name="scan_dns" value="YES">-DNS 
    <input type="checkbox" name="scan_http" value="YES">-HTTP 
    <input type="checkbox" name="scan_pop3" value="YES">-POP3
	<br>
    <br>
    Port Number Range: 
    <input type="text" id="scan_range1" name="scan_range1" size="6" maxlength="6"> - <input type="text" id="scan_range2" name="scan_range2" size="6" maxlength="6"> 
    Maximum range {RANGE}
    <br>
    <!-- BEGIN line_break -->
    {BR} 
    <!-- END line_break -->
    <br>
    <input value="Scan" type="submit">
    <input type="reset">
  </p>
</form>