Having trouble requesting a FTH website

Hi there
I am trying to request a FTH website for a chartered club. The system repeatedly doesn't accept the District number as well as the club number. After some repeated attempts, those are accepted. However, the Submit button doesn't appear to work. I have tried several times, but don't receive an email or any other indication that the request has been submitted.

Please advise.
District Number: 74
Club Number: 2249

Thanks in advance

It looks like a breaking change (not our change) was recently made to a Perl code module that we use...  I am trying to sort out what we now need to do differently to make everything work again.  I request your patience as I figure this out.

Please try the form again... I was able to work around the change made to the code module.