Please print the following form and return it by mail with the correct payment by check, money order or Credit Card. All drafts should be written payableto: Heart of Asia. If you send cash, please send it by registered mail.
Mail to:
Heart of Asia,  3525 Del Mar Heights Road #408, Del Mar, CA 92130  USA

fax 1-213-341-0808
Country:_________________________Zip Code:______________________

Screenname: ________________________________

E-Mail Address :_______________________________

Email address repeat:____________________________________

Choose One
Gold Membership { } 1 Month $29.99 { } 3 Month $59.99 { } 6 Month $99.99 { } 1 Year $119.99
Silver Membership { } 1 Month $24.99 { } 3 Month $49.99 { } 6 Month $74.99 { } 1 Year $99.99

                                               Total Enclosed   $________
Payment Method

___ Money Order (US$ payable on US Bank)  ___ International Postal MoneyOrder(US$ Payable on US Bank) (Sorry No Canadian Postal Orders, these arenot payable on a US bank) ___ Cash Currency US$ send via REGISTERED mailONLY.
___ American Express Card ___ Visa ___ MasterCard____Discover

All payments should be in US $dollars. Checks or drafts should be issuedby U.S. Banks made payable to Heart of Asia. Bankers Drafts are preferred. 

Credit Card Information

Credit Card Number:_________________ Issue:_____ Expiry:_____

Security Code ________ (The security code is printed in thesignature panel on the back of the credit card. For
American Express it is printed on the front of the card. See

Your Name as printed on Card(Please Print):_____________________________

If paying by Credit Card please sign as follows: I hereby authorise Heart of Asia to debit my Credit Card, indicated above by the amount of $________US dollars.

Signature_________________________ Date _________________

Comments: ________________________________________________________________________________________________

Last Updated 12/01/12