The image appears to be a screenshot of a website or online form. The form is divided into several sections with various fields and options. Here is a detailed description:

1. **Header Section:**
   - There is a header with a yellow background containing text that seems to be related to the website or form.
   - The header also has a logo or icon on the left side.

2. **Main Form Fields:**
   - The main form consists of multiple fields, each with a label and corresponding input field.
   - The fields include:
     - **First Name:** "First Name"
     - **Last Name:** "Last Name"
     - **Email Address:** "Email Address"
     - **Phone Number:** "Phone Number"
     - **Address:** "Address"
     - **City:** "City"
     - **State:** "State"
     - **Zip Code:** "Zip Code"
     - **Country:** "Country"
     - **Postal Code:** "