The image you are looking at is known as a "captcha". In order to submit the form, you must enter the text seen in the image into the text box. All letters are upper-case, and numbers only range from 1-9.
If you can't make out the text, click the refresh link seen below the image. Don't worry, this does not reload the page, it will only change the image. This way you don't lose the info you have already typed up.