\documentclass{article}

\usepackage[utf8]{inputenc}

\begin{document}
\section*{LONI Training Account}
Each participant is expected to have an \texttt{SSH} client installed on their
personal computers. This is needed to login to the LONI cluster \texttt{QueenBee}
(\texttt{queenbee.loni.org}).\\[2em]

Please fill out the following form and return it.\\[2em]

\begin{tabular}{p{6cm}|p{6cm}}
Account:   & \verb|trainXX|\\
\hline\\
Password:  & \verb|PASSWD|\\
\hline\\
Your name: &\\
\hline\\
Your email:&\\
\hline\\
Your title: (student, prof., ect.)&\\
\hline\\
Department:&\\
\hline\\
Insitution:&\\
\hline\\
Race: (Optional - NSF reporting)&\\
\hline\\
Gender: (Optional - NSF reporting)&\\
\end{tabular}

\end{document}