That is some shitty ass phisher. The GUI is horrible.
When I used to phish in 2009-2010, this is the phisher I had. Thanks to -XpliCitt-.

(I deleted the part where it asks for Date of Birth)
I know it doesn't ask for last name or first name but back then, there was a method/glitch to get the account's first and last name. There was also birthday cracker.
I uploaded a video acting like I actually got the NX and put the phisher on YouTube and my video had 60k+ legit views. Here's how many people downloaded the file in media fire.
I got like over 30k logs because some were repeats.
YouTube deleted my video so I stopped doing this.
Anyways, your phisher is asking for too much account infos. Only new CA players or low rank accounts would actually put this correctly. Old players or people with high ranks wouldn't put their info like this. That GUI isn't very convincing. You can just tell it's some random vB program/phisher. On top of all this, you're actually selling this for that much money?
