How to write the information related to referees in an application form?
Looks to me like you've left out the "organization" and the mailing address. I'd change line 2 to something like: "Associate Professor, Department of Physics, The University of Exampleville". Then you should add several lines below the telephone number that gives the work mailing address of your recommender. If they can't provide that to you directly, you can almost certainly provide the departmental mailing address which should be on their website.