Need help with formatting on the form

Post 2 of 2....here's what I need it to look like: (see attached)

The other thread is being addressed by one of our colleagues. I have forwarded the screenshot provided here to take a look. So, we are marking this thread as answered and if you have any questions with this issue, we request you to follow-up on the other thread to avoid any confusion.

https://www.jotform.com/answers/1105830

Thank you!