Choose a valid combination of City and State or something like that.
First choose the State of residence as Hokkaido.
Then enter your phone number with the area code of 123(a certain city inside Hokkaido).
Replace the XXX-XXXX with any numbers.
And names have to be in kanji. Picture taken from the first post.
Ignore the all characters have to be the same, it's just saying Last Name and First Name.
But top and bottom has to be the same though, because the second one is confirmation.
You can put this in the left box: 明
This into the right box: 太月