re create the attached

We need the attached pdf re-created. need to be able to have fillable fields that I can type in and save the document. info below number 8 does not have to have fillable fields as they will be signed by hand. Please make sure your document has a top 3” margin on the 1st page. Please make sure you have a 1” margin on the left, right and bottom sides of the 1st page. $10 max bid for this project