Form that submits to multiple autoresponders through checkboxes

I need a script that will let a person submit their name and email address to multiple autoresponders through the use of check boxes. An example can be seen here: [login to view URL] The form needs to submit an name and email address to ANY set of autoresponders from any company depending on which check boxes are selected. Documentation should indicate where the script can be modified to include more or fewer check boxes as needed. Thanks. ## Deliverables Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. Complete copyrights to all work purchased. ## Platform Should be a cgi script capable of running on UNIX servers.