I've been having the exact same issue today, even tried using the page source to figure out the correct info for each box(they are labeled there). Each time I click submit I get kicked back to the same screen with all the fields blank and no new information or warnings. I thought I was taking crazy pills, but it's the same on 5 browsers across 3 OS. Something is busted, it's a shame because like, I want to give them my money and they apparently don't want to take it.