form for "cutting edge'

<div style="background-color:666;padding:10px;text-align:center;color:91AA8D">
<div style="margin-right:250px;margin-top:20px"><img src="http://i.imgur.com/rCfFhno.jpg" style="width:140px;border: solid 2px ccc"></div>

<div style="letter-spacing:5px;text-align:center;width:140px;margin:0px 273px 0px 25px;font-size:20px">
<div style="background-color:000">
<a href="link"style="color:cccccc;"><b>LINK</a></div>
<div style="margin-top:10px;background-color:000">
<a href="link"style="color:cccccc;"><b>LINK</a></div>
<div style="margin-top:10px;background-color:000">
<a href="link"style="color:cccccc;"><b>LINK</a></div></div>
<div style="background-color:000;padding:8px;margin: -170px 10px 0px 190px;font-size:11px;color:ccc;padding-bottom:30px;text-align:justify"><u>I AM REQUESTING A COVER</u>
<br>title
<br>subtitle*
<br>author
<br>ideas/pictures (at least two pictures for manip)
<br>mood/colour scheme
<br>anything else
<br></div>

<div style="letter-spacing:-7px;font-size:55px;color:ccc;margin:-25px 0px 0px 180px"><b>cutting edge</div>
<div style="letter-spacing:-7px;font-size:55px;color:000;margin:-19px 0px 0px 180px"><b>cutting edge</div>
<div style="letter-spacing:1px;font-size:7px;color:ccc;margin: 10px 0px 0px 180px">CODED BY TIMESHATTERED | INPSO BY ECLACITY