I need help D:!

[lovingtheasian]

So i'm trying to sign up for PSO2
I got up to the part where you sign up and enter your info.
Everytime I try to go to the next page it says something in japanese 1~12 please help me!

[Lostbob117]

Can we see a picture?

[lovingtheasian]

http://i50.tinypic.com/5156ie.jpg
Always when I try to continue