Application Form remade for print

I need the attached file remade, the original artwork was lost and we need to add new logo and addresses, we will do that part if we can get the form recreated. Form should be designed in Illustrator or Indesign, we want the file editable so photoshop is not acceptable The attached scan should be remade exactly without need for the logo or addresses at the top, suitable for print. Need delivery for Wednesday September 19th