The image appears to be a screenshot of a webpage or a form, with various sections and fields. The main focus is on a section labeled "CITY" with three options: "HCM," "LH," and "Dong." There are also two buttons, one marked with an "X" and another with a circle, possibly indicating different actions or selections. The overall layout suggests it might be related to a survey, poll, or some other form of online interaction where users can choose their city or location.