Everything nice. But why you ask for so much info? For what purposes it will be used? Who are you to know all this data? Why you need to know my name and my address? I don´t understand that.
Are you bank or government structure? I fully disagree to provide all this data to you, without explanation for what it will be used.
We fill up the form and know our information, I do not know why they want our information and who we are and where we come from.
Yh, it is nice. But... My name and my address is my private data. I am not going to share it with some not really trustworthy ICO project. In Germany you can do a lot of things with name and address.