Interactive fill in Blank or Text Entry or Other?

I want learners to correctly fill out a withdrawal slip. I would like them to figure out where to type in the correct information. If I use a text entry , it's a tip off to where they need to fill in. Is there a way to have them fill this out without seeing where they have to fill in?  For example, I want them to fill out the Cash and Total, Account Number and put an X in the boxes for Checking and PIN. I've included an attachment. Thanks for any help!

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