How to write the information related to referees in an application form?

What's the best way to give information about the person who's going to give recommendation letter, in an application form?

John Clark, Ph.D. in Physics and Mathematics

Associate Professor

Teacher of 'Web Programming' course during the 6th semester

Email address: email.address@example.com

Telephone Number: +00 1234 5678

Is there any need for the 3rd line, at all? Do I need to add information related to the department the person is working in?