icon form

<BLOCKQUOTE STYLE="BACKGROUND-COLOR:#bab096;">
<center> <img src="http://i.imgur.com/aEms0zw.png" width:450px;"></a><br>
<center> <div style="background-color:#bab096; text-align: center; color: FFFFFF; font-family: verdana; text-transform: lowercase; 10px; margin-right: 50px; margin-left: 50px;">
<br><br><b>Simple [] Manipulated []</b>
<br><br><b>+Text:</b> TEXT HERE
<br><br><b>+Model/Celeb:</b> TEXT HERE
<br><br><b>+Ideas:</b> TEXT HERE
<br><br><b>+Picture(s)*:</b> TEXT HERE
<br><br><b>+Mood:</b> TEXT HERE
<br><br><b>+Colors/Color Scheme:</b> TEXT HERE
<br><br><b>+Anything Else:</b> TEXT HERE
</div>