Please attach the actual page when posting to the forum instead of using copy/paste. That enables me to open the page in Dreamweaver and debug it more easily.
In this case, try changing:
<form action="<?php echo htmlspecialchars($_SERVER["PHP_SELF"]);?>" method="POST" role="form" class="form">
to:
<form action="" method="POST" role="form" class="form">
I think that will resolve the problem.