Create a dog tag generator to use in eBay Listing

I am looking for an Army Dog Tag generator to use in eBay listings. eBay listings have restrictions on the use of Active Content so this needs to be taken into account. See here for details [login to view URL] The generator should look something like this [login to view URL] Each line should be restricted to 15 characters The only characters permitted are; A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 1 2 3 4 5 6 7 8 9 0 & ' , . - / ( ) @ * + ~ ! ? " : An additional field will be required for the customer to enter their eBay ID The Add to Cart button should send an email with a copy of the customer requirements to me. eMail to provide 5 lines as per the user entry Thanks