How to say please put your name and address, please. in Japanese

1)ここにここに(kokoni) (adv) individually/separately住所住所(juusho) (n) address/residence/domicileとおとお(too) (adj-no) distant名前名前(namae) (n) name/full name/given name/first name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,お(o) (int) oh!/polite prefix to the next word願い願い(negai) (n) desire/wish/request/prayer/petition/applicationしますします(shimasu) (v) polite present form of "to do"。(。) Japanese period "."    
kokoni juusho too namae woo negai shimasu 。
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