The problem is that there is no drop down menu where you enter your address.
it seems to me the problem in html format in theform file so try to open it in the source by notepad++ editor
and copy it then go to theform file in the site and open it
select all delete it and past the source in it then save .
any way i'm here for your help at any time and as i said before you can send me login page to file manager details and i will
install it for you and you can change details after that.