10151 Deerwood Park Blvd. Bldg 400, Ste 220 Jacksonville, Fl. 32258 Office (904) 746-4257 Fax (904) 297-3155

Credit Card Payment Form E-mail to: [email protected] Fax: 904-297-3155 NAME________________________________________________________________________ PRINT NAME HERE EXACTLY AS IT APPEARS ON THE CARD ADDRESS____________________________________________________________________ CITY______________________________________ STATE________ ZIP___________________ PHONE (________) ___________-_______________

CREDIT CARD TYPE: (Circle Type)

AMEX

VISA

MASTERCARD

CARD # ____________________________________ EXP_______________ CVV2 NUMBER_______________ (appears on the white strip on the back of the card following your credit card number - 3-digit number for VISA/MASTERCARD and a 4-digit number for AMEX

I_____________________________ DO HEREBY AUTHORIZE FAITH CHRISTIAN ACADEMY OF JACKSONVILLE TO CHARGE $_________________ TO THE ABOVE NOTED CREDIT CARD FOR GOODS AND SERVICES RECEIVED.

SIGNATURE_________________________________DATE_____________________________