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Payment Form!

Goliath Academy
15165 N.W. 77TH AVE; STE 2003
Miami, FL 33014
http://www.GoliathAcademy.org

Ph:  305-512-5994

Fax: 305-512-5996


Please provide the following contact information:

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Street Address
Address (cont.)
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FAX
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Choose one of the following options:

CREDIT CARD NUMBER

EXPIRATION DATE

NAME AS IT APPEARS ON CARD

Name

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Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone

AMOUNT OF PAYMENT

ANY INSTRUCTION, QUESTIONS, OR COMMENTS? YOU WILL RECEIVE A CONFIRMATION VIA E-MAIL WITHIN A FEW HOURS!


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GOLIATH ACADEMY
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Copyright � 2008 [Goliath Academy]. All rights reserved.
Revised: 05/21/10