





                             GLACI-HTTPD ORDER FORM
                             ======================


     Company Name: ______________________________________________________

     Contact Name: ______________________________________________________

     Phone Number: ________________

     Fax Number:   ________________

     Email Address: _______________________________________

     
     Shipping Address: __________________________________________________

                       __________________________________________________

                       __________________________________________________

                       __________________________________________________

     
     Billing Address:  __________________________________________________

                       __________________________________________________

                       __________________________________________________

                       __________________________________________________

     
     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 = ________





