<form action="http://cl.s4.exct.net/subscribe.aspx" name="subscribeForm" method="post">
    <input type="hidden" id="thx" name="thx" value="">
    <input type="hidden" name="err" value="YOUR ERROR PAGE HERE" />
    <input type="hidden" name="usub" value="YOUR SUCCESS UNSUB PAGE HERE" />
    <input type="hidden" name="MID" value="7238068" />
    <input id="popup-email" type="text" value="email address" name="Email Address">
    <input class="pop-checkbox hidden" type="checkbox" id="everyone" name=lid value="31491">
    <input type="radio" name="SubAction" value="unsub" />
    <input type="submit" value="Submit" /></td>
    </form>