How to say fill in your name and address here. in Japanese

1)ここにここに(kokoni) (adv) individually/separately名前名前(namae) (n) name/full name/given name/first nameと(to) (prt,conj) if/when/and/with/particle used for quoting/quoting particle/ promoted pawn/ indicates question住所住所(juusho) (n) address/residence/domicileを(wo) (prt) indicates direct object of action/indicates subject of causative expression/indicates an area traversed/indicates time over which action takes place/indicates point of departure or separation of action/indicates object of desire, like, hate,書きno dictionary result, likely a conjigated verbno dictionary result, likely a conjigated verbなさいなさい(nasai) (exp) firm command to do (previous verb)/do。(。) Japanese period "."    
kokoni namae to juusho wo kaki nasai 。
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