FYI anyone else trying to use this,I had to add the following as a row in the sample new request form before submit would work:

    <tr class="evenRow" valign="top">
        <td>DOMAIN_NAME</td>
        <td>:</td>
        <td><input type="text" class="txt" NAME="DOMAIN_NAME" value="" style="width:200px;" /></td>
    </tr>

Also, I had to change the FORM ACTION URL from http to https.