Convert and Adobe fillable PDF to a Word mail merge

I need an exact replication of the attached PDF in a word mail merge template. I am going to use the resulting file in an application where I map variables into merge fields to a Word Template (dotx). I have some specific names for the fields that I will provide on acceptance of the estimate. The font size used in the mail merge fields needs to match the PDF sample, and the file should render just like the PDF. There are around 100 fields, but most are check boxes or the letter "s" to make something plural. there is no need for the digital signature or dates with the signatures, as we will be creating a copy that will be printed.