convert scanned form to fillable PDF

Attached is a scan of our credit application used by our customers for credit with our company. We have since lost the original and the copies are now getting to the point of being illegible. I wouuld like you to re-create this form as a fillable pdf file that can be filled on-screen then printed? or by hand? and then faxed back to us. Also included is a jpg of the new logo to be used. Another change we would like to make is to have a "Please complete and fax back to 303-286-0406" statement on the form instead of listing the fax numbers for the three stores. I realize that some words may be hard to make out...do your best and I'll catch any mistakes? in the proof or contact me with specific questions.