SECURITY AGREEMENT

     THIS SECURITY AGREEMENT ("Agreement") dated May 17, 1999, is
made   between   The  Exploration  Company  of  Louisiana,   Inc.
("Grantor") and Northern Securities Limited ("Lender"), who agree
as follows:

                            Recitals

     1.   XCL Land, Ltd. ("XCL Land") is or will be indebted unto the
Lender  for  loans  made or to be made and evidenced  by  certain
notes, including, but not limited to that certain Promissory Note
by  XCL  Land payable to the order of Lender dated of  even  date
herewith (the "Note").

     2.   The making of such loans will be of substantial benefit to
the  Grantor, and, consequently, in order to secure the full  and
punctual  payment and performance of the Indebtedness as  defined
herein,  the  Grantor  has  agreed to execute  and  deliver  this
Agreement and to pledge, deliver and grant a continuing  security
interest in and to the Collateral (as hereafter defined).

                            AGREEMENT

     NOW,  THEREFORE,  in  consideration  of  the  premises,  the
Grantor and the Lender agree as follows:

     Section 2.     Definitions.

          1.   The terms "Agreement," "Grantor," "Lender," "Note," and "XCL
Land" shall have the meanings indicated above.

          2.   As used in this Agreement, the following terms shall have
the following meaning:

          "Event  of  Default" shall have the meaning defined  in
the Note.

          "General  Intangibles" has the meaning given to  it  in
the UCC.

           "Lien" shall mean any interest in property securing an
obligation owed to, or a claim by, a Person other than the  owner
of the property, whether such interest is based on jurisprudence,
statute or contract, and including but not limited to the lien or
security  interest arising from a mortgage, encumbrance,  pledge,
security agreement, conditional sale or trust receipt or a lease,
consignment  or bailment for security purposes. The  term  "Lien"
shall include reservations, exceptions, encroachments, easements,
servitudes,   usufructs,  rights-of-way,  covenants,  conditions,
restrictions, leases and other title exceptions and  encumbrances
affecting  property.  For the purposes  of  this  Agreement,  the
Grantor shall be deemed to be the owner of any property which  it
has  accrued  or  holds subject to a conditional sale  agreement,
financing lease or other arrangement pursuant to which  title  to
the  property has been retained by or vested in some other Person
for security purposes.
          "New  Funds"  means funds advanced to  Borrower  on  or
after November 6, 1998 through the purchase of Units or otherwise
up to the aggregate outstanding principal amount of $6,200,000.

          "Permitted Liens" means (i) the Security Interests  and
any  other Liens created, assumed or existing with respect to the
Collateral in favor of Lender or in favor of any other  purchaser
of  Units  or  other provider of New Funds to XCL Land  (provided
that  the  Liens in favor of such other persons do not cause  the
percentage  stated in Sections 2(A)(1) and 2(A)(2) hereof  to  be
less  than the percentage of total New Funds provided by  Lender)
and  (ii)  any other Liens permitted by Lender in writing  to  be
created or assumed or to exist with respect the Collateral.

          "Person"    means    any    individual,    corporation,
partnership,  joint  venture, association, joint  stock  company,
trust,  unincorporated organization, government or any agency  or
political subdivision thereof, or any other form of entity.

          "Proceeds" has the meaning giving to it in the UCC.

          "Security  Interests" means the security  interests  in
the  Collateral and Proceeds granted hereunder in favor of Lender
securing the Indebtedness.

          "Subscription    Agreement"    means    that    certain
Subscription  Agreement dated  May 17, 1999 by  and  between  XCL
Land,  Lender  and  XCL  Ltd.  and  any  subsequent  subscription
agreement  for  additional Units entered into  between  the  same
parties.

          "UCC"  means  the  Uniform Commercial Code,  Commercial
Laws  - Secured Transactions (Louisiana Revised Statutes 10:9-101
through  :9-605) in the State of Louisiana, as amended from  time
to  time;  provided that if by reason of mandatory provisions  of
law, the perfection or the effect of perfection or non-perfection
of  the  Security Interests in any Collateral is governed by  the
Uniform Commercial Code as in effect in a jurisdiction other than
Louisiana, "UCC" means the Uniform Commercial Code as  in  effect
in  such other jurisdiction for purposes of the provisions hereof
relating   to   such  perfection  or  effect  of  perfection   or
non-perfection.

          "Units"  has  the  meaning defined in the  Subscription
Agreement.

     Section 3.     Security Interest.

          1.   To secure the full and punctual payment and performance of
all  present  and  future amounts, liabilities,  obligations  and
indebtedness  of  XCL  Land  to the  Lender,  including,  without
limitation  all promissory notes (including, but not  limited  to
the  Note)  heretofore  or hereafter executed  by  XCL  Land,  in
principal, interest, deferral and delinquency charges as  therein
stipulated,  whether such amounts, liabilities,  obligations  and
indebtedness  be  liquidated  or unliquidated,  now  existing  or
hereafter arising (collectively, the "Indebtedness"), the Grantor
hereby  pledges,  pawns, transfers and grants  to  the  Lender  a
continuing  security  interest in and to  all  of  the  following
property  of  the  Grantor,  whether now  owned  or  existing  or
hereafter acquired or arising (collectively the "Collateral"):

          (1)  35.71% of Grantor's now owned or hereafter acquired
               partnership interest (the "Partnership Interest") (which
               Partnership Interest is currently a limited partner interest) in
               L.M. Holding Associates, L.P., a Louisiana Partnership in
               Commendam (the "Partnership"), which Partnership was created by
               that certain Agreement of Limited Partnership dated May 27, 1991,
               as amended by amendments filed with the Louisiana Secretary of
               State on February 25, 1993, August 19, 1994, September 1, 1994,
               October 7, 1994 and January 8, 1997 (the "Partnership
               Agreement");

          (2)  35.71% of any and all monies and other distributions (cash
               or property), allocations or payments made or to be made to
               Grantor pursuant to the Partnership Agreement or attributable to
               the Partnership Interest;

          (3)  all General Intangibles related in any way to the collateral
               described in clauses 1 or 2 above; and

          (4)  all Proceeds and products of all or any of the collateral
               described in clauses 1-3 above.

          2.   The security interests are granted as security only and
shall not subject the Lender to, or transfer or in any way affect
or  modify,  any  obligation or liability  of  the  Grantor  with
respect to any of the Collateral or any transaction in connection
therewith.

     Section 4.     Delivery of Collateral if Ever Represented by
Certificates. If the Partnership Interest is ever represented  by
a  certificate of interest or any similar document, the  Borrower
will  immediately  deliver such certificate or  document  to  the
Lender  or  to  an  agent that Lender and all  other  holders  of
security interests in Grantor's Partnership Interest have  agreed
shall hold the certificate or document on their behalf.

     Section 5.     No Liens.  Other than financing statements or
other similar or equivalent documents or instruments with respect
to  the  Security  Interests and Permitted  Liens,  no  financing
statement,  mortgage, security agreement or similar or equivalent
document or instrument covering all or any part of the Collateral
is  on file or of record in any jurisdiction in which such filing
or  recording  would  be  effective to perfect  a  Lien  on  such
Collateral.   No Collateral is in the possession  of  any  Person
(other  than  Grantor) asserting any claim  thereto  or  security
interest  therein,  except that Lender or its designee  may  have
possession  of  Collateral as contemplated hereby.   Except  with
respect  to Permitted Liens, the Liens granted pursuant  to  this
Agreement  constitute  perfected  first  priority  Liens  on  the
Collateral in favor of the Lender.

     Section 6.     No Conflict.  The Grantor has not performed any
acts or signed any agreements which might prevent the Lender from
enforcing any of the terms of this Agreement or which would limit
the Lender in any such enforcement.

     Section 7.     Name.  The full name of Grantor is as it appears
on page 1 of this Agreement.

     Section 8.     Federal Taxpayer Number.  The federal taxpayer
identification number of Grantor is as follows:  72-1123077.

     Section  9.     Chief Executive Office.  The chief executive
office  of  Grantor is 110 Rue Jean Lafitte, Lafayette, Louisiana
70505.

     Section 10.    Location of Collateral.  Grantor will keep and
maintain  all books or records relating to any of the  Collateral
at its chief executive office.

     Section 11.    Filing Location.  When a UCC financing statement
has  been  filed in the offices of a Louisiana Clerk of Court  of
any  parish other than Orleans (or in the case of Orleans Parish,
with  the  Recorder of Mortgages), the Security  Interests  shall
constitute perfected security interests in the Collateral to  the
extent  that  a  security interest therein may  be  perfected  by
filing  pursuant to the UCC, prior to all other Liens except  for
the  Permitted Liens and rights of others therein to  the  extent
that such priority is afforded by the UCC.

     Section 12.    Title.  Grantor has good and merchantable title to
the   Collateral,   free   of  Liens  except   Permitted   Liens.
Furthermore,  Grantor has not heretofore conveyed  or  agreed  to
convey or encumber any Collateral in any way, except in favor  of
Lender  or  other holders of Permitted Liens.  Lender understands
and agrees, however, that Grantor has granted a security interest
in all of its Partnership Interest in the Partnership (other than
the  percentage  of its Partnership Interest covered  hereby)  to
those persons or entities who have previously purchased Units  or
provided other New Funds.  Lender further agrees and acknowledges
that  in  the event that additional Units are sold or  additional
New  Funds  are  provided to XCL Land after the  date  hereof  by
persons other than Lender and secured by partnership interests in
L.M.  Holding, Lender will immediately upon demand  by  XCL  Land
(one  or  more times, as appropriate) execute amendments to  this
Agreement  releasing  a  percentage of the Grantor's  Partnership
Interest  sufficient to allocate the security  interests  in  the
partnership  interest of L.M. Holding among the Unit  holders  or
other  providers of New Funds on a proportionate basis  (provided
that  no  reduction in such security interest need be  made  with
respect  to  amounts of New Funds in excess of  an  aggregate  of
$6,200,000 principal outstanding).

     Section  13.    Incorporation and Existence.  Grantor  is  a
corporation duly organized, validly existing and in good standing
under  the laws of the jurisdiction of its organization  and  has
the  corporate power and authority and the legal right to own and
operate the Collateral and to conduct the business in which it is
currently engaged.

     Section  14.    No Consents or Approvals.  Except for  those
filings  and registrations required to perfect the Liens  created
by  this  Agreement, the Grantor is not required  to  obtain  any
order, consent, approval or authorization of, or required to make
any declaration or filing with, any governmental authority or any
other  Person  in connection with the execution and  delivery  of
this  Agreement and the granting and perfection of  the  Security
Interests pursuant to this Agreement.

     Section 15.    Due Execution; Binding Obligation.  This Agreement
has  been  duly executed and delivered on behalf of the  Grantor,
and  this  Agreement  constitutes  a  legal,  valid  and  binding
obligation  of Grantor, enforceable against Grantor in accordance
with  its  terms,  except as enforceability  may  be  limited  by
applicable bankruptcy, insolvency, reorganization, moratorium  or
similar  laws  affecting the enforcement  of  creditors'   rights
generally and except as enforceability may be subject to  general
principles  of equity, whether such principles are applied  in  a
court of equity or at law.

     Section  16.     No Conflicts.  The execution, delivery  and
performance  of  this  Agreement  will  not  (I)  result  in  any
violation of or be in conflict with or constitute a default under
any terms of any agreement, contract, statute, regulation, law or
ordinance; (ii) have a material adverse effect on the Collateral;
(iii)  materially  adversely affect the  ability  of  Grantor  to
perform  its  obligations under this Agreement or  the  Note,  or
(iv)  result  in  the  creation of  any  Lien  upon  any  of  the
properties or revenues of Grantor other than the Liens  in  favor
of the Lender created pursuant to this Agreement.

     Section  17.    Voting Rights.  Notwithstanding the security
interest  granted hereby and whether or not an Event  of  Default
(as  defined in the Note) shall have occurred, the Grantor  shall
have  the exclusive right to exercise all voting and other rights
under  the  Partnership Agreement until such time (if  and  when)
Lender  forecloses  on  the  Collateral  and  becomes  the  owner
thereof.

     Section 18.    Notice of Changes.  Grantor will not change its
name, corporate identity or taxpayer identification number in any
manner  unless it shall have given Lender at least five (5)  days
prior written notice thereof.

     Section 19.    Remedies upon Default.

          1.   Sale.  Upon the occurrence of an Event of Default, Lender
may  exercise  all rights of a secured party under  the  UCC  and
other applicable law (including the Uniform Commercial Code as in
effect  in  another  applicable jurisdiction) and,  in  addition,
Lender may, without being required to give any notice, except  as
herein provided or as may be required by mandatory provisions  of
law, sell the Collateral or any part thereof at public or private
sale,  for cash, upon credit or for future delivery, and at  such
price  or prices as Lender may deem satisfactory.  Lender may  be
the  purchaser  of any or all of the Collateral so  sold  at  any
public sale (or, if the Collateral is of a type customarily  sold
in  a  recognized market or is of a type which is the subject  of
widely  distributed  standard price quotations,  at  any  private
sale).  Grantor will execute and deliver such documents and  take
such other action as Lender deems necessary or advisable in order
that any such sale may be made in compliance with law.  Upon  any
such  sale  Lender  shall have the right to deliver,  assign  and
transfer  to the purchaser thereof the Collateral so sold.   Each
purchaser at any such sale shall hold the Collateral so  sold  to
it  absolutely  and  free from any claim or right  of  whatsoever
kind,  including  any  equity or right of redemption  of  Grantor
which may be waived, and Grantor, to the extent permitted by law,
hereby  specifically  waives all rights of  redemption,  stay  or
appraisal which it has or may have under any law now existing  or
hereafter  adopted.   Grantor agrees that  ten  (10)  days  prior
written  notice  of  the time and place  of  any  sale  or  other
intended   disposition  of  any  of  the  Collateral  constitutes
"reasonable notification" within the meaning of Section  9-504(3)
of  the  UCC,  except that shorter notice or no notice  shall  be
reasonable as to any Collateral which is perishable or  threatens
to decline speedily in value or is  of a type customarily sold on
a  recognized  market.  The notice (if any) of  such  sale  shall
(1)  in case of a public sale, state the time and place fixed for
such  sale, and (2) in the case of a private sale, state the  day
after  which  such sale may be consulted.  Any such  public  sale
shall  be  held  at  such time or times within ordinary  business
hours and at such place or places as Lender may fix in the notice
or such sale.  At any such sale the Collateral may be sold in one
lot  as  an  entirety  or  in separate  parcels,  as  Lender  may
determine.  Lender shall not be obligated to make any  such  sale
pursuant  to  any  such notice.  Lender may,  without  notice  or
publication, adjourn any public or private sale or cause the same
to be adjourned from time to time by announcement at the time and
place  fixed for the sale, and such sale may be made at any  time
or  place to which the same may be so adjourned.  In case of  any
sale of all or any part of the Collateral on credit or for future
delivery, the Collateral so sold may be retained by Lender  until
the  selling price is paid by the purchaser thereof,  but  Lender
shall  not  incur  any liability in case of the failure  of  such
purchaser to take up and pay for the Collateral so sold  and,  in
case  of any such failure, such Collateral may again be sold upon
like notice.

          2.   Foreclosure.  Instead of exercising the power of sale herein
conferred upon it, Lender may proceed by a suit or suits  at  law
or  in  equity to foreclose the Security Interests and  sell  the
Collateral, or any portion thereof, under a judgment or decree of
a court or courts of competent jurisdiction.  FOR THE PURPOSES OF
LOUISIANA  EXECUTORY  PROCESS  PROCEDURES,  GRANTOR  DOES  HEREBY
CONFESS  JUDGMENT IN FAVOR OF LENDER FOR THE FULL AMOUNT  OF  THE
INDEBTEDNESS.  GRANTOR DOES BY THESE PRESENTS CONSENT, AGREE  AND
STIPULATE  THAT  UPON THE OCCURRENCE OF AN EVENT  OF  DEFAULT  IT
SHALL BE LAWFUL FOR LENDER, AND THE GRANTOR DOES HEREBY AUTHORIZE
LENDER, TO CAUSE ALL AND SINGULAR THE COLLATERAL TO BE SEIZED AND
SOLD  UNDER  EXECUTORY  OR  ORDINARY PROCESS,  AT  LENDER'S  SOLE
OPTION,  WITH OR WITHOUT APPRAISEMENT, APPRAISEMENT BEING  HEREBY
EXPRESSLY  WAIVED,  IN  ONE LOT AS AN  ENTIRETY  OR  IN  SEPARATE
PARCELS  AS  LENDER  MAY DETERMINE, TO THE  HIGHEST  BIDDER,  AND
OTHERWISE  EXERCISE  THE  RIGHTS, POWERS  AND  REMEDIES  AFFORDED
HEREIN  AND  UNDER  APPLICATION  LOUISIANA  LAW.   ANY  AND   ALL
DECLARATIONS OF FACT MADE BY AUTHENTIC ACT BEFORE A NOTARY PUBLIC
IN  THE PRESENCE OF TWO WITNESSES BY A PERSON DECLARING THAT SUCH
FACTS   LIE  WITHIN  HIS  KNOWLEDGE  SHALL  CONSTITUTE  AUTHENTIC
EVIDENCE  OF  SUCH   FACTS FOR THE PURPOSE OF EXECUTORY  PROCESS.
GRANTOR  HEREBY  WAIVES IN FAVOR OF LENDER: (A)  THE  BENEFIT  OF
APPRAISEMENT  AS  PROVIDED IN LOUISIANA CODE OF  CIVIL  PROCEDURE
ARTICLES 2332, 2336, 2723 AND 2724, AND ALL OTHER LAWS CONFERRING
THE  SAME;  (B)  THE  DEMAND AND THREE  DAYS  DELAY  ACCORDED  BY
LOUISIANA CODE OF CIVIL PROCEDURE ARTICLES 2639 AND 2721; (C) THE
NOTICE  OF  SEIZURE REQUIRED BY LOUISIANA CODE OF CIVIL PROCEDURE
ARTICLES  2293  AND  2721; (D) THE THREE DAYS DELAY  PROVIDED  BY
LOUISIANA  CODE OF CIVIL PROCEDURE ARTICLES 2331  AND  2722;  AND
(E)  THE  BENEFIT  OF THE OTHER PROVISIONS OF LOUISIANA  CODE  OF
CIVIL  PROCEDURE  ARTICLES 2331, 2722 AND 2723, NOT  SPECIFICALLY
MENTIONED ABOVE.

          3.   Effect of Securities Laws.  The Grantor recognizes that the
Lender  may be unable to effect a public sale of all or  part  of
the Collateral by reason of certain prohibitions contained in the
Securities  Act  of  1933,  as  amended,  and  applicable   state
securities  laws but may be compelled to resort to  one  or  more
private  sales to a restricted group of purchasers  who  will  be
obligated to agree, among other things, to acquire all or a  part
of  the Collateral for their own account, for investment, and not
with  a view to the distribution or resale thereof. If the Lender
deems  it  advisable  to  do so for the foregoing  or  for  other
reasons,  the  Lender  is  authorized to  limit  the  prospective
bidders  on  or  purchasers of any of the Collateral  to  such  a
restricted  group of purchasers and may cause  to  be  placed  on
certificates  for any or all of the Collateral a  legend  to  the
effect  that  such  security has not been  registered  under  the
Securities Act of 1933, as amended, and may not be disposed of in
violation of the provision of said act, and to impose such  other
limitations or conditions in connection with any such sale as the
Lender deems necessary or advisable in order to comply with  said
act   or   any  other  securities  or  other  laws.  The  Grantor
acknowledges and agrees that any private sale so made may  be  at
prices  and on other terms less favorable to the seller  than  if
such Collateral were sold at public sale and that the Lender  has
no obligation to delay the sale of such Collateral for the period
of  time  necessary to permit the registration of such Collateral
for  public  sale under any securities laws. The  Grantor  agrees
that   a   private  sale  or  sales  made  under  the   foregoing
circumstances shall be deemed to have been made in a commercially
reasonable manner. If any consent, approval, or authorization  of
any  federal, state, municipal or other governmental  department,
agency or authority should be necessary to effectuate any sale or
other disposition of the Collateral, or any partial sale or other
disposition  of  the  Collateral, the Grantor  will  execute  all
applications  and  other  instruments  as  may  be  required   in
connection   with   securing  any  such  consent,   approval   or
authorization and will otherwise use its best efforts  to  secure
same.

     Section 20.    Limitation on Duty of Lender.  Beyond the exercise
of  reasonable care in the custody thereof, the Lender shall have
no  duty as to any Collateral in its possession or control or  in
the  possession or control of any agent or bailee or  any  income
thereon.  The Lender shall be deemed to have exercised reasonable
care  in the custody of the Collateral in its possession  if  the
Collateral  is  accorded treatment substantially  equal  to  that
which  it  accords its own property, and shall not be  liable  or
responsible  for any loss or damage to any of the Collateral,  or
for any diminution in the value thereof, by reason of the act  or
omission of any broker or other agent or bailee selected  by  the
Lender  in  good  faith.  The Lender  shall  be  deemed  to  have
exercised  reasonable care with respect to any of the  Collateral
in  its  possession  if  the Lender takes such  action  for  that
purpose  as the Grantor shall reasonably request in writing;  but
no  failure to comply with any such request shall, of itself,  be
deemed a failure to exercise reasonable care.
Section 1.

     Section 21.    Appointment of Agent.  At any time or times, in
order  to  comply with any legal requirement in any jurisdiction,
the  Lender  may appoint a bank or trust company or one  or  more
other  Persons with such power and authority as may be  necessary
for  the effectual operation of the provisions hereof and may  be
specified in the instrument of appointment.

     Section 22.    Expenses.  All sums incurred by the Lender in
enforcing or protecting any of the rights or remedies under  this
Agreement, together with interest thereon until paid at the  rate
equal  the then highest rate of interest charged on the principal
of  any  of  the  Indebtedness plus one percent  (1%),  shall  be
additional Indebtedness hereunder and the Grantor agrees  to  pay
all of the foregoing sums promptly on demand.

     Section 23.    Termination.  Upon the payment in full of the
Indebtedness, this Agreement shall terminate. Upon request of the
Grantor,  the  Lender shall deliver the remaining Collateral  (if
any)  to  the  Grantor.   Upon request of Grantor,  Lender  shall
execute  and  deliver  to  Grantor  at  Grantor's  expense   such
termination  statements  as  Grantor may  reasonably  request  to
evidence such termination.

     Section 24.    Notices.  Any notice or demand which, by provision
of this Agreement, is required or permitted to be given or served
to  the  Grantor  and  the Lender shall be deemed  to  have  been
sufficiently  given  and  served for  all  purposes  if  made  in
accordance with the Note.

     Section  25.    Amendment.  Neither this Agreement  nor  any
provisions   hereof  may  be  changed,  waived,   discharged   or
terminated orally or in any manner other than by an instrument in
writing  signed  by  the party against whom  enforcement  of  the
change, waiver, discharge or termination is sought.

     Section 26.    Waivers.  No course of dealing on the part of the
Lender,  its officers, employees, consultants or agents, nor  any
failure or delay by the Lender with respect to exercising any  of
its  rights,  powers  or privileges under  this  Agreement  shall
operate as a waiver thereof.

     Section 27.    Cumulative Rights.  The rights and remedies of the
Lender  under this Agreement shall be cumulative and the exercise
or  partial  exercise  of  any such right  or  remedy  shall  not
preclude the exercise of any other right or remedy.

     Section 28.    Titles of Sections.  All titles or headings to
sections  of this Agreement are only for the convenience  of  the
parties  and shall not be construed to have any effect or meaning
with  respect to the other content of such sections,  such  other
content being controlling as to the agreement between the parties
hereto.

     Section 29.    Governing Law.  This Agreement is a contract made
under  and shall be construed in accordance with and governed  by
the  laws  of  the  United States of America  and  the  State  of
Louisiana.

     Section  30.     Successors and Assigns.  All covenants  and
agreements made by or on behalf of the Grantor in this  Agreement
shall  bind Grantor's successors and assigns and shall  inure  to
the benefit of the Lender and its successors and assigns.

     Section 31.    Counterparts.  This Agreement may be executed in
two  or more counterparts, and it shall not be necessary that the
signatures  of  all  parties  hereto  be  contained  on  any  one
counterpart hereof, each counterpart shall be deemed an original,
but all of which when taken together shall constitute one and the
same instrument.

     IN  WITNESS WHEREOF, the Grantor and the Lender have  caused
this  Agreement  to be duly executed as of the date  first  above
written.

WITNESSES:                    THE    EXPLORATION    COMPANY    OF
                              LOUISIANA, INC.


_________________________    By:___________________________________
Name:____________________       Name:______________________________
      (Please Print)            Title:_______________________________


_________________________
Name:____________________
        (Please Print)
                              LENDER:

                              NORTHERN SECURITIES LIMITED



_________________________     By:______________________________________
Name:____________________        Name:_____________________________
       (Please Print)            Title:______________________________


_________________________
Name:____________________
        (Please Print)