I am updating the Client Perm Block Addon and need some feedback please

I just updated the Non-client theat form for the Client Perm Block Addon Module, and needed some feedback. This is not a new module i am just updating it. There is a video available if you need to see it.

Attached are the two photos of the top part of the form and the bottom part. Just wanted to get some feed back as far as layout and if you feel there is enough data collected to serve the purpose. Also if there is data that you might need that is not on here please advise. The form is explained at the top of the form. But basically the client perm block addons job partly is to prevent sales from people you never want to deal with again or those you have been warned about by others. This form (of several) will allow you pre determine via the data provided and what we call a push factor, wether you want to do business with this client or not. It is a local way of dealing with a world issue.

Your thoughts are appreciated.

top part

bottom part

thanks dave