This form is for individuals who have violated membership terms and who now wish to have their profiles unblocked.

HeartofAsiaOnline provides Anonymous email boxes, and instant messaging
for members to contact each other. While it is acceptable for you to give your personal contact information directly to the member you are corresponding with, it is not acceptable to publish your contact info publicly at your profile.

Please print the following form and return it by mail with the correct payment by check, money order or cash. All drafts should be written payable to: 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

Name:___________________________________________________________

Address:________________________________________________________

City:_________________________State/Prov:_______________________

Country:_________________________Zip Code:______________________

Phone:_______________________Fax:_______________________________

Screenname: ________________________________

E-Mail Address :_______________________________

Email address repeat:____________________________________

Choose One
Silver Membership { } 1 Month $24.99 { } 3 Month $49.99 { } 6 Month $74.99 { } 12 Month $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.

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

I understand and accept the terms and conditions published at http://www.heartofasiaonline.com/terms_of_use.php

I understand and accept that under no circumstances may any contact information, such as but not limited to my address, name, email, telephone number, or instant messenger account, or  Html codes such as but not limited to web links, emails, web pages, urls  etc. be  published at my profile.

I further understand and accept that should I violate these terms that my membership will be blocked, without refund, without notice.


Signature_________________________ Date _________________


 
Last Updated 7/20/7