The first line with a checked options has:
[x] New Tefillin  Used Tefillin
The next horizontal line indictes writing Style:
 Sepharadi / Yemenite  Ashkenaz - Ar"i [x] Ashkenaz - Beis Yosef
The vertical checklist gives the quality:
[x] Basic - Mehudar [ ] "small animal" - leather from sheep or goats [ ] "small animal" one piece - the tefillin are made from a single piece of leather [ ] "large" - leather from cows [ ] "Miksha A/B" - single piece of "large animal" leather.
There is an empty line for special requests.
Results of the Kashrus check:
[ ] pasul [ ] Kosher Bedieved - Kosher, but no so great [x] Kosher with no problems [ ] Mehudar - really nice
There is another empty line for comments from the one who checked the Tefillin.
"This form is also a warranty"