Heart of Asia Romance Network - Printable Order Form

Send a Kiss

IMBRA Compliant Service to Help US clients contact
Foreign Clients

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 payable to: Heart of Asia. If you send cash, please send it by registered mail. Mail to: Heart of Asia,PMB# 131,2658 Del Mar Heights Road,Del Mar, CA 92014 USA
fax/Tel 1-(213)-596-6277, or 1-(888)-311-8885

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

E-Mail Address (neatly) (all lower case):_______________________________

Email address again (all upper case):____________________________________

I have read and agree to abide by the terms and conditions published at http://www.heart-of-asia.com/gen/pledge.html.
I understand and agree that Heart of Asia Romance Network is an information service 
and makes no other promises. I hereby waive any and all claims against Heart of Asia, its 
employees and directors.

Signature required:__________________________Date:_____________

Send A Kiss         All prices are in US Dollars
 1 Kiss   = $ 15        2 - 5  Kisses = @$10   6 - 10 addresses = @$8

 
=========================================================================
                                                  Sub Total     $________
                     
                                               Total Enclosed   $________

Comments:____________________________________________________________________

If you are ordering addresses please write the member's number of the women whose addresses you want.

1._________2._________3._________4._________5._________6._________
7._________8._________9._________10.________11.________12.________
13.________14.________15.________16.________17.________18.________
19.________20.________21.________22.________23.________24.________
25.________26.________27.________28.________29.________30.________
31.________32.________33.________34.________35.________36.________
37.________38.________39.________40.________41.________42.________

If you order over 42 addresses, please attach second sheet of paper

In case any or your selections above are not available at the time your order is processed, and in case
some selections are typed twice. Please choose alternates
so we can process your order without delay.
First ________ Second ________ Third_________

Payment Method

___ Money Order (US$ payable on US Bank) ___ International Postal Money Order(US$ Payable on US Bank) (Sorry No Canadian Postal Orders, these are not payable on a US bank) ___ Cash Currency US$ send via REGISTERED mail ONLY.
___ American Express Card ___ Visa ___ MasterCard____Discover

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. Personal checks are not acceptable.

Credit Card Information

Credit Card Number:_________________ Issue:_____ Expiry:_____

Security Code ________ (The security code is printed in the signature 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 _________________