The image shows a scanned document with a form at the top that is partially filled out and includes handwritten notes. The form contains lines for writing information such as name, address, and other personal details. There are checkboxes on the form which appear to be unchecked. The text is too small to read clearly in this description. In addition to the form, there is a section at the bottom of the document that seems to contain additional notes or instructions, but these are not entirely visible due to the image's resolution.