Simple Intergration required.

Need to add this Captcha :Securimage CAPTCHA - Free PHP Captcha Script
Adding to this page : Submit Your Proxy Site

Code:
<?php
include "config.php";
$detect=$_SERVER['PHP_SELF'];
$detect2=$_SERVER['SERVER_NAME'].$_SERVER['PHP_SELF'];
$detect3=explode("/",$detect2);
$count=count($detect3);
$ddd="";
for ($i=0;$i<$count-1;$i++){
 if ($i==0){
 $ddd=$detect3[$i];
}else{$ddd=$ddd."/".$detect3[$i];}
}
$detect3=$ddd."/";
$flag=0; $insert_flag=1;
if (isset($_POST['url']) and isset($_POST['category']) and isset($_POST['email'])){
$link = mysql_connect("$db_host", "$db_user", "$db_pass"); // host,username,password
mysql_select_db($db_name);
 $flag=1;
 $url=$_POST['url'];
 $category=$_POST['category'];
 $email=$_POST['email'];
 
   $query = "SELECT * FROM submission";
       $result = mysql_query($query) or die("");
   $count=-1;
       while ($line = mysql_fetch_row($result)){
         $count++;
    $file[$count]=$line[0]; 
      }
 
   $query = "SELECT * FROM approve";
       $result = mysql_query($query) or die("");
 
       while ($line = mysql_fetch_row($result)){
         $count++;
    $file[$count]=$line[0]; 
      }
$url_x=$url;
if (strstr($url,'http://')){
 $url_x=str_replace('http://','',$url);
}
if (strstr($url,'www.')){
 $url_x=str_replace('www.','',$url_x);
}
 
   for ($i=0;$i<=$count;$i++){
    //if ($url==$file[$i]){
    if (strstr($file[$i],$url_x)){
     $insert_flag=0; $flag=0; break;
    }
 
  }
if ($insert_flag!=0){
 $time=time();
 $query = "INSERT INTO `approve` (`url`, `category`, `email`, `time`) VALUES ('$url', '$category', '$email', '$time');";
 $result = mysql_query($query) or die("");
$headers  = "MIME-Version: 1.0
";
$headers .= "Content-type: text/html; charset=windows-1251
";
$headers .= "From: $email
";
$checklink=@file($url);
$checkcount=count($checklink);
$checkflag="No";
for ($i=0;$i<$checkcount;$i++){
 if (strstr($checklink[$i],"$detect3")){
  $checkflag="Yes"; break;
 }
}
 
$msg="Proxy URL: <a href=$url>$url</a><br>====================<br>
Category: $category<br>====================<br>
E-mail: <a href=mailto:$email>$email</a><br>====================<br>
Backlink: $checkflag<br>====================<br>
<br><br>
<a href='http://$detect3"."admin.php'>Go to admin area</a>
";
mail("$admin_email","New Proxy Site \"$url\" submitted", $msg, $headers);
 
$file=@file("subemail.txt");
$count=count($file);
$file_subject=@file("subemail_subject.txt");
$count_subject=count($file_subject);
$msg="";
for ($i=0;$i<$count;$i++){
 $msg.=$file[$i];
}
$headers  = "MIME-Version: 1.0
";
$headers .= "Content-type: text/html; charset=windows-1251
";
$headers .= "From: $admin_email
";
mail($email,$file_subject[0],$msg,$headers);
 
 
}
}
?>
<?php include "template/top.tpl"; ?>
 
    <b><font face="Verdana" size="2">Submit your Proxy Site! </b> </font>
 
    </div> 
   <div id="pageNav"> 
   <div id="sectionLinks" style='height: <?php include "config.php"; print ($links_num*24);?>px; overflow: auto; width: 100%'> 
 
<?php
$recent_num=19; // Number of recent categories
?>
 
<?php include "php/currently_active_proxies.php"; ?>
</div>
</div>
  <div id="content">
    <div class="feature">
 
<?php
if ($insert_flag==0){
echo <<<D
<b><br><br><font face=Verdana size=2>Proxy Already Listed
</b><br><br>
This proxy is already listed or pending to be listed.</font>
D;
}
if ($flag==1){
 
echo <<<D
<b><br><br>
<font face=Verdana size=2>Submission Received
</b><br><br>
 Thank you for your submission, it has been received.<br> Once approved, your listing should be live within 24 hours.<br><b> A link back is required for a guaranteed listing on our site. </b><br>Please use the following to link to our site:
<br><br>
<form method=get name=f onSubmit="return false;">
<input type=text name=l value='<a href="http://$detect3">Web Proxies</a>' size=40 onclick="document.f.l.focus();document.f.l.select();">
</form>
<br><br>
</font>
D;
}
?>
 
 
 
<table cellpadding=0 cellspacing=0 width=800><tr><td>
      <br>
     <font face="Verdana" size="2"> Get your proxy listed at Sneek.In, by meeting our requirements:
<br>
<br>
   1. <b>A backlink is required. If we dont see it, we wont accept you.</b><br><br>
   <span style="color:#CC0000;font-weight:normal;">&lt;a href=&quot;http://sneek.in/&quot;&gt;Web Proxies&lt;/a&gt;</span></li>
   <br>
   <br>
   2. Web Proxies only. We will <b>NOT</b> accept proxy listing sites!
   <br>
   3. Free domains will <b>NOT</b> be accepted!
   <br>
 
</a>
      <p>
<script language="JavaScript">
 function check(){
  if (document.form.url.value=='' || document.form.url.value=='http://' || document.form.email.value==''){
   alert('Please fill empty fields!'); return false;
  }
 }
</script>
<form method=post action="" name=form onSubmit="return check();">
 
<div id="sectionLinks"> 
  <strong><font face="Verdana" size="2">Website URL</strong></font><br>
  <br>
<input type=text name=url value='http://' style='width:250px'><br><br>
<strong><font face="Verdana" size="2">Category</strong></font><br>
<br>
<select name="category">
<?php
$cat_list=@file("categories.txt");
$count_cat=count($cat_list);
for ($i=0;$i<$count_cat;$i++){
echo <<<D
 <option value="$cat_list[$i]">$cat_list[$i]</option>
D;
}
?>
</select><br><br>
<strong><font face="Verdana" size="2">Email</strong></font><br>
<br>
<input type=text name=email style='width:250px'><br><br>
<input type=submit value='Submit'> 
</div> 
</form>
</td><td valign=middle width=100>
 
  <p>&nbsp;</p></td></tr></table>
     </p>
<?php include "template/bottom.tpl"; ?>