[ Image 1 ]
Usually your Company Logo    [ Color 1 - background ]
[ Image 2 ]
[ Color 5 - background ]
    [ Color 3 - background ]

[ Title ]
[ Color 2 ]
[ Color 3 - background ]
Text Field One:       
Text Field Two:       
Text Field Three:       
Checkbox Field Four:      
Select Field Five:       
[ Color 4 - background ]   
Radio Button Six:   
   
Yes No

[ Color 3 - background ]
[ Color 4 - background ]   
Text Area Seven:   
   
Text Field Eight:       
Text Field Nine:       
Text Field Ten:       
Text Field Eleven: