This form fails in 2 main categories. It is hard to follow /complete and its appearance does not build trust nor maintain branding.
Branding: Overall the entire site needs help in this category. Specifically with this form it tries to group the fields into multiple categories with a yellow bar and horizontal line. This yellow color does not appear anywhere else on the site, in addition they could have used a font that went more with the look of the rest of the site.
Although that gradient bar is hideous, they could have tied it in with the submit button.
Appearance: It is very hard to read the white on yellow text. Visually if you squint the entire thing kind of looks like a double stuffed vanilla golden oreo:
The main thing is that this form does not look trustworthy. The main thing that stands out to me is that if I click submit I will be charge $75, this is not inviting nor does it create trust.
The worst part is the address section:
You can't tell what text box goes with what label. Also the 3 boxes for City/State/Province should not be on the same line.