Heart of Asia Romance Network- Personal Listing

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Please print the following form and return it with your correct payment by check, money order or Credit Card. All checks must be in US dollars payable on a USA bank. You may also send cash, however if you do so, please only send it by registered mail. Please mail to:

Heart of Asia Romance Network,

Heart of Asia, 2658 Del Mar Heights Road #159, Del Mar, CA 92014 USA
Tel 1-800-806-3210 x703 (toll free USA) , or Tel 1-(213) 596-6277 x703 (International)
Fax 1-(213) 596-6277

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


We will send out 500 pieces of For ladies Only, each containing your
advertisement.

What Nationality is your preference to have these sent to?  (Tick One)

___Filipino  ___ Ethiopian   ___ Chinese/Thai/Vietnamese

BONUS: Choose Id Number of up to 5 members to SEND a KISS to:


1)___________  2)___________  3)___________  4)___________  5)___________  Alternate)___________

I understand and agree that Heart of Asia 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:_____________

Prices Ladies Only Advertisement in US $

Advertisement in For Ladies Only members magazine 
  Your sent to 500 members)       $  97

Heart of Asia reserves the right to select which ads to publish. Obscene, sexually explicit wording is not acceptable. Prices subject to change without notice.

Payment Method
___ Money Order (US$ payable on US Bank) ___ Personal Check (US$ drawn on US Bank)(Order held 2 wks for clearing) ___ 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 acceptable, however your order will be delayed pending clearing of check.

Credit Card Information

Credit Card Number:_________________ Expiry date:_____ Security Code:_____

Name on Card(Please Print):___________________________________

Payment Summary

For Ladies Only Advertisement                $97 =  _________
                 
                                            Total Enclosed       _________

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

Signature_________________________ Date _________________

Mail to: Heart of Asia, 2658 Del Mar Heights Road #159, Del Mar, CA 92014
USA 

Tel 1-800-806-3210 x705 (toll free USA) , or Tel 1-(213) 596-6277 x705 (International)
Fax 1-(213) 596-6277

04/15/2009