I called SCTFlash technical support and this is how they told me to do it:
Put the date at the top, and leave the first column ("LICENSOR" column) totally blank. This is how the rest goes:
LICENSEE
Name of Entity: Your name here
Form of Entity: Individual
Jurisdiction of Organization: Your state here
By: Your name here again
Its: Leave blank
Address: Your address here
Fax: Fax number of the fax machine you're using to send it to them
License Fee: Leave blank because there is none
