GLACI-HTTPD ORDER FORM
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     Company Name: ______________________________________________________

     Contact Name: ______________________________________________________

     Phone Number: ________________

     Fax Number:   ________________

     Email Address: _______________________________________

     
     Shipping Address: __________________________________________________

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     Billing Address:  __________________________________________________

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     Type of floppy disk:  (___) 3.5 inch   (___) 5.25 inch

     Number of server licenses =  _______ X unit price _______ = ________

     Shipping cost (USA = $4.00, International = $10.00)       = ________


                                                         TOTAL = ________