Icon Form

<BLOCKQUOTE STYLE="BACKGROUND-COLOR:#000000;">

<center> <img src="http://i.imgur.com/3UYZ7GO.png?2" width:450px;"></a><br>
<center> <div style="background-color:; text-align:center; color: FFFFFF; line-height: 10px; margin-right: 50px; margin-left: 50px; text-transform:uppercase;">

<br>
<b><DIV STYLE="FONT-SIZE:20PX">Requesting an icon</DIV><br></b>
<p>
<p>
username[]text[]*:: text here<br>
<p>
mood:: text here<br>
<p>
color scheme*:: text here<br>
<p>
ideas:: text here<br>

</div>