166730 Customize text for graphic

I want to create something similar to this [login to view URL];combo_id=4298&gallery_id=221&category_id=11177&referer=http%3a%2f%[login to view URL]%2fvp%2fns%[login to view URL]%3fGP%3d10%252F9%252F2006%2b10%253A33%253A44%2bPM But instead of using many business card templates, I just want to use one image (this is the actual image that will be used for this project): [login to view URL] The user can fill the image so that it looks like this: [login to view URL] There are six fields that can be customized: [login to view URL] 1. Date 2. Your name 3. Currency symbol 4. Currency text 5. Value (number) 6. Value (text) After filling those fields, the user can right click and save as to download the filled image. Thanks! Aldian PS. You can use other than Javascript or PHP (No ASP please, I host my site on Linux server).