Could someone help me out putting my autoresponder data into a template?

Hi,
I am having a bit of trouble putting my Imnica form data into a nice opt in template I would like to use. I would appreciate some help.

Here is the template data;
<tr>
<td width="246">
<div align="center" class="style27"><span class="style122">ACCESS YOUR FREE <br />
AB SECRETS REPORT:</span><font size="1"><br />
</font></div>
</td>
</tr>
<tr>
<td>
<p class="style119">Enter your email address in the form below for instant access to the AB SECRETS REPORT...</p>
<p align="center" class="style119"><img height="50" src="http://www.get-six-pack-abs.org/wp-content/uploads/2009/12/3.gif" width="108" /></p>
</td>
</tr>
<tr>
<td>
<form action="https://www.imnicamail.com/v4/subscribe.php" method="post" name="form1"><input id="merchantid" name="merchantid" type="hidden" value="123456" /> <input id="ARThankyouURL" name="ARThankyouURL" type="hidden" value="http://www.yoursite.com/thankyoupage.html" /> <input id="copyarresponse" name="copyarresponse" type="hidden" value="1" /> <input id="custom" name="custom" type="hidden" value="0" /> <input id="defaultar" name="defaultar" type="hidden" value="328363" /> <input id="allowmulti" name="allowmulti" type="hidden" value="0" /> <input id="visiblefields" name="visiblefields" type="hidden" value="Email1" /> <input id="requiredfields" name="requiredfields" type="hidden" value="Email1" />
<table align="center">
<tbody>
<tr>
<td>
<div align="center"><input name="Email1" size="30" value="Enter Valid Email Here" /> <br />
&nbsp;</div>
</td>
</tr>
<tr align="middle">
<td colspan="2">
<div align="center"><input name="cmdSubmit" src="http://www.get-six-pack-abs.org/wp-content/uploads/2009/12/2.gif" type="image" /></div>
</td>
</tr>
</tbody>
</table>
</form>
<p align="center" class="style18">**Double-check your email for accuracy to ensure you receive the report.</p>
<p align="center" class="style18"><a href="privacy.html" target="_blank">Privacy Assured</a>: Your email address is never shared with anyone.</p>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</div>
</td>
</tr>

Here is my imnica form data;
<form action="http://www.imnicamail.com/v4/subscribe.php" method="post">
Email Address<br />
<input type="text" name="FormValue_Fields[EmailAddress]" value="" id="FormValue_EmailAddress"><br /><br />
<br />
<br /><br />
<input type="submit" name="FormButton_Subscribe" value="Subscribe" id="FormButton_Subscribe">
<input type="hidden" name="FormValue_ListID" value="665" id="FormValue_ListID">
<input type="hidden" name="FormValue_Command" value="Subscriber.Add" id="FormValue_Command">
</form>


Can anyone help me out? I'm not sure what I have to keep. etc....

Thanks