The form above is not very complete. If a field isn't filled in a floating box appears alerting that a field hasn't been filled in correctly. Is this a guessing game or a query form? The field in question should be highlighted or at least the focus should be returned to the field that requires attention.

There's no mask input for the date either.

Sorry but if i run into forms like these when I'm trying to communicate with a web site owner i just give up and go to a site that works.

only my 2 cents.