Automatic Proxy Topsite Submitter

I need a site that will allow me to submit a proxy to a list of proxy topsites I've pre-configured. The script should ask for the site name, URL, username, password, email, etc... If the topsite contains a CAPTCHA the script should display the CAPTCHA image with a box next to it for me to enter the code which it will use to submit to the site. When completed the code needed to add to the submitted proxy should be provided. This should be a fairly easy project and I would like to get it completed quickly. Post on the DB with an questions.