How to say will you fill out this form, please? in Japanese

1)このこの(kono) (n) thisカードカード(kado) (n) card/curdに(ni) (prt) indicates such things as location of person or thing, location of short-term action, etc.記入記入(kinyuu) (n,vs) entry/filling in of forms(num) 10^24/septillion/quadrillionていただけますno dictionary result, likely a conjigated verbか(ka) (prt) indicates question/indicates choice, doubt, etc.。(。) Japanese period "."    
kono kado ni kinyuu shiteitadakemasuka 。
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