ICON FORM - S/V

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<div style="background-color:#373833;padding:10px;text-align:center;font-size:11px;font-family:century;letter-spacing:1px;text-transform:lowercase;color:FF6A5B;"> <span style="font-size:25px;font-family:arial;letter-spacing:-2px;text-transform:uppercase;"> <b>R<i>E</i>QUES<i>T</i>IN<i>G</i> AN ICO<i>N</i></b></span>
<br> <b> ideas: </b> [ text here ]
<br> <b> text:* </b> [ text here ]
<br> <b> theme/mood: </b> [ text here ]
<br> <b> picture:* </b> [ text here ]
<br> <b> notes: </b> [ text here ]
<br> <b> password: </b> [ text here ]