Please print the following form fill in the details, then fax or mail it to us with your Western Union receipt attached.
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 { } 3 Month $59.99 { } 6 Month $99.99 { } 1 Year $119.99
Silver Membership { } 3 Month $49.99 { } 6 Month $74.99 { } 1 Year $99.99


                                               Membership Fee   $________

                                               Service Charge   $ 10  

                                               Total Enclosed   $________

Visit your nearest Western Union or Money Gram representative and instruct them to send the payment as follows:

Send the funds to:

Joyce Wahl Attn: Heart of Asia

3525 Del Mar Heights Road #408, Del Mar, CA 92130 USA.

1-800-806-3210 x705 ( toll free USA)
1-213-341-0808 x705 (International) 

Note: It is very important that you write : Joyce Wahl as the recipient. This designated individual will have to make a special trip to their offices to pick up the payment, unfortunately they will not transfer money to the company name.

Once the transfer has been made, write the Western Union or Money Gram transaction number, to this form, then fax or email the order information to us at 1-800-806-3210 x705 ( toll free USA)
1-213-341-0808 x705 (International) . Once Western Union or Money Gram confirms the payment has arrived your order will be processed.

Western Union or Money Gram transaction number

Control Number:_________________

Security Question and Answer ________ __________________________________(In case you provide a security question, provide the answer here

Remember to Attach your Western Union or MoneyGram receipt and FAX or Mail it together with this form.   Last Updated 12/01/12