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
Name:___________________________________________________________
Address:________________________________________________________
City:_________________________State/Prov:_______________________
Country:_________________________Zip Code:______________________
Phone:_______________________Fax:_______________________________

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 http://www.heart-of-asia.com/gen/cvs.html

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