banner/blend form

<div style=" padding-top: 10px; padding-left: 100px; font-family:'century gothic'; color: #4C3F3F; padding-right: 100px; font-size:12px; "><left-align><b><i><u>i am requesting a...BANNER/BLEND</u></i></b></left-align><br></div>
<div style=" padding-top: 10px; padding-left: 100px; font-family:'century gothic'; color: #4C3F3F; padding-right: 100px; font-size:10px ">
<b>banner</b> { } OR <b>blend</b> { }
<br>
<b>text* |</b> {TYPE here}
<br>
<b>mood |</b> {TYPE here}
<br>
<b>ideas |</b> {TYPE here}
<br>
<b>anything ELSE* |</b> {TYPE here}