The image is a screenshot of a form with various fields and options. The form appears to be for an online transaction or payment, as indicated by the presence of buttons and text fields. Here is a detailed description of the form:

1. **Header Section:**
   - The top part of the form has a header with some text and icons.
   - There is a logo on the left side.

2. **Fields:**
   - There are several fields in the form:
     - **First Name:** "John"
     - **Last Name:** "Doe"
     - **Email:** "john.doe@example.com"
     - **Phone Number:** "123-456-7890"
     - **Address:** "123 Main St, Anytown, USA"
     - **City:** "Anytown"
     - **State:** "CA"
     - **Zip Code:** "90001"
     - **Country:**