The image is a screenshot of a form in Spanish that asks the user to enter their name and address in order to register for a service. The form is titled "16ª que espera encontrar en los servicios brindados por el Registro Nacional? Ordene según importante, siento 1 lo más importante y 7 lo menos importante" which translates to "How to register your service for the registro" in English. 

There are six fields in the form, each with a title and a brief description. The first field is for the user's name, the second field is labeled "Efficiencia", the third field is filled in with the following information, the fourth field is blank, and the fifth field is empty.

At the bottom of the form there is a button that says "Restablecer" which is used to enter the name of the service they want to register. There is also a checkbox next to the "Personal capacitado" field, indicating that the user can enter their personal capacity.