EXHIBIT 99



                         BIRMINGHAM UTILITIES, INC.

                              STOCK OPTION PLAN
                         FOR NON-EMPLOYEE DIRECTORS



                        BIRMINGHAM UTILITIES, INC.
                              STOCK OPTION PLAN
                         FOR NON-EMPLOYEE DIRECTORS



1.  Purpose.

    The purpose of the Birmingham Utilities, Inc. Stock Option Plan for
Non-Employee Directors (the "Plan") is to promote the interests of Birmingham
Utilities, Inc. (the "Company") and its shareholders by encouraging 
Non-Employee Directors of the Company to have a direct and personal stake 
in the performance of the Company's Common Stock.

2.  Definitions.

   Unless the context clearly indicates otherwise, the following terms have
the meanings set forth below.  Whenever applicable, the masculine pronoun 
shall include the feminine pronoun and the singular shall include the plural.

   "Board of Directors" or "Board" means the Board of Directors of the
   Company.

   "Business Day" shall mean any day except Saturday, Sunday or a legal
   holiday in the State of Connecticut.

   "Code" means the Internal Revenue Code of 1986, as amended, now in effect
   or as amended from time to time and any successor provisions thereto.

   "Committee" means the Personnel and Pension Committee of three or more
   members appointed by the Board of Directors and selected from those
   directors who are not employees of the Corporation, its parent or any
   Subsidiary, as defined in Section 424(e) and (f) of the Code.  The Board
   may at any time and from time to time remove any member of the Committee,
   with or without cause, appoint additional members to the Committee and
   fill vacancies, however caused, in the Committee. A majority of the
   members of the Committee shall constitute a quorum.  All determinations of
   the Committee shall be made by a majority of its members.  Any decision or
   determination of the Committee reduced to writing and signed by all of the
   members of the Committee shall be fully as effective as if it had been
   made at a meeting duly called and held.

   "Common Stock" means the common stock, without par value, of the Company.

   "Company" means Birmingham Utilities, Inc., a Connecticut corporation.

   "Disability", as applied to a Grantee, shall have the meaning set forth in
   Section 22(e)(3) of the Code.

   "Fair Market Value" of a share of Common Stock on any particular date is
   the average of the high and low sales price of a share of Common Stock on
   the NASDAQ Small Cap Market (or any exchange on which the Common Stock is
   then traded) as reported for that date by NASDAQ or, if no sales price is
   reported for that date, the average bid quotation for the Common Stock on
   that date as reported by NASDAQ; provided, however, that if no such sales
   or quotation are reported by NASDAQ for such date, the Fair Market Value
   of a share of Common Stock on such date shall be the average of the high
   and low sales price or, if no sales price is reported for that date, the
   average bid quotation as reported by NASDAQ for the first Business Day
   immediately after such date on which such sales or quotation are reported.

   "Grant Date", as used with respect to a particular Option, means the date
   on which such Option is granted pursuant to the Plan.

   "Grantee" means the Non-Employee Director to whom an Option is granted
   pursuant to the Plan.

   "Immediate family members" of a Grantee means the Grantee's children,
   grandchildren and spouse. 

   "Option" means an option granted pursuant to the Plan to purchase shares
   of Common Stock which shall be a non-qualified stock option not intended
   to qualify as incentive stock options under Section 422 of the Code.  

   "Non-Employee Director" shall mean a member of the Board of Directors who
   is not an employee of the Company or any Subsidiary.

   "Plan" means the Birmingham Utilities, Inc. Stock Option Plan for
   Non-Employee Directors as set forth herein and as amended from time to
   time.

   "Retirement", as applied to a Non-Employee Director, shall mean when a
   Grantee ceases to serve as a member of the Board following attaining
   sixty-five (65) years of age.

   "Subsidiary" shall mean a "subsidiary corporation" of the Company as
   defined in Section 425(f) of the Code. 

   "The 1934 Act" means the Securities Exchange Act of 1934, as amended, now
   in effect or as amended from time to time and any successor provisions
   thereto.

3.  Administration.

   (a)  General.  The Plan shall be administered by the Committee, which 
shall have full power and authority, subject to the provisions of the Plan, 
to supervise administration of the Plan and interpret the provisions of the 
Plan and any Options granted hereunder.  Any decision by the Committee shall 
be final and binding on all parties.  No member of the Committee shall be 
liable for any determination, decision or action made in good faith with 
respect to the Plan or any Options under the Plan.  The Committee may 
delegate any of such responsibilities to one or more agents and may retain 
advisors to advise it.  No Grantee shall participate in the decision of any 
question relating exclusively to an Option granted to that Grantee.

   (b)  Rules and Interpretation.  The Committee shall be vested with full
authority to make such rules and regulations as it deems necessary to 
administer the Plan and to interpret and administer the provisions of the 
Plan in a uniform manner.  Any determination, decision or action of the 
Committee in connection with the construction, interpretation, 
administration or application of the Plan shall be final, conclusive and 
binding on all parties.  The Committee's administrative functions shall be 
ministerial in nature in view of the Plan's explicit provisions, including 
those related to eligibility for, timing, price and amount of Option grants.

4.   Eligibility.

   The persons eligible to receive Options under the Plan are the Non-
Employee Directors of the Company.

5.   Effective Date of the Plan and Term of Option Period.

   The Plan shall become effective upon its adoption by the Board of
Directors, provided, that no Option granted pursuant to the Plan shall be
exercised or will vest prior to (1) the approval of the Plan by the Company's
shareholders within twelve (12) months of its adoption by the Board, and (2) 
the approval of the Plan by the Connecticut Department of Public Utility 
Control.  The term during which awards may be granted under the Plan shall 
expire on the tenth anniversary of the adoption of the Plan by the Board of 
Directors.  Subject to the provisions of Article 12 hereof, the period during 
which an Option granted under the Plan may be exercised shall expire on the 
tenth anniversary of the Grant Date of the Option.

6.   Shares Subject to the Plan.

     The shares of Common Stock that may be delivered upon the exercise of
Options under the Plan shall be shares of the Company's authorized Common 
Stock and may be unissued shares or reacquired shares, as the Board of 
Directors may from time to time determine.  Subject to adjustment as provided 
in Article 13 hereof, the aggregate number of shares to be delivered under 
the Plan shall not exceed 40,000 shares.  If any shares are subject to an 
Option which for any reason expires or terminates during the term of the
Plan prior to the issuance of such shares, the shares subject to but not 
delivered under such Option shall be available for issuance under the Plan.  
If, on any Grant Date, the aggregate number of shares of Common Stock subject 
to Option grants on that date exceeds the remaining number of shares reserved
for issuance under the Plan, the number of Option shares awarded to each 
Non-Employee Director to whom Options shall be granted on such date shall be
reduced pro rata so that the aggregate number of Option shares awarded to 
such Non-Employee Directors equals the number of reserved shares of Common 
Stock remaining under the Plan. 

7.  Options.

    (a)  Grant of Options.  On September 13, 1994, each Non-Employee Director
of the Company shall be granted an Option, upon the terms and conditions
specified in the Plan, to purchase 2,500 shares of Common Stock plus a number
of shares of Common Stock determined by multiplying the number of whole years
of previous service as an Non-Employee Director of the Company by 1,250.
Commencing on August 1, 1995 and on each August 1st thereafter (or, if August
1st is not a Business Day, the first preceding Business Day) during the term 
of the Plan, each Non-Employee Director of the Company shall automatically 
be granted a stock option to purchase 1,250 shares of Common Stock upon the 
terms and conditions specified in the Plan.  Notwithstanding the foregoing 
provisions of this paragraph, no Non-Employee Director shall receive Options 
under the Plan to purchase more than an aggregate amount of 5,000 shares of 
Common Stock.   

   (b)  Terms of Options.  Each Option granted under the Plan shall have the
following terms and conditions:

       (i)  Price.  The exercise price per share of each Option shall equal
            the greater of the Fair Market Value of a share of Common Stock
            on the Grant Date or the par value per share of the Common
            Stock, if any, on the date of exercise of such option; 

      (ii)  Term.  The term of each Option shall be for a period of ten (10)
            years from the Grant Date unless terminated earlier in
            accordance with the Plan;

     (iii)  Time of Exercise.  Unless an Option is terminated or the time of
            its exercisability is accelerated in accordance with the Plan,
            each Option shall be exercisable only to the extent of one-half
            of the number of shares of the Common Stock to which it relates
            on or after the first anniversary of its Grant Date and shall be
            exercisable to the extent of the remaining one-half of such
            shares only on or after the second anniversary of the Grant
            Date, so that the Options shall be exercisable in full only on
            or after the second anniversary of the Grant Date.

      (iv)  Acceleration of Exercisability.  Notwithstanding the schedule
            provided in subparagraph (iii) hereof, an Option shall become
            fully exercisable upon the occurrence of the Grantee's death or
            withdrawal from the Board of Directors by reason of such
            Non-Employee Director's Disability or Retirement; and

      (v)   Option Agreement.  Each Option shall be evidenced by an Option
            Agreement substantially in the form attached to this Plan as
            Appendix A.

8.   Exercise of Options.

     (a)  Each Option granted shall be exercisable in whole or in part at 
any time, or from time to time, during the Option term as specified in the 
Plan, provided that the election to exercise an Option shall be made in 
accordance with applicable Federal laws and regulations.  Each Option may be 
exercised by delivery of a written notice to the Company stating the number 
of shares to be exercised and accompanied by the payment of the Option 
exercise price therefor in accordance with this Article.  The Grantee shall 
furnish the Company, prior to the delivery of any shares upon the exercise 
of an Option, with such other documents and representations as the Company 
may require, to assure compliance with applicable laws and regulations.

     (b)  No Option may at any time be exercised with respect to a fractional
share.  In the event that shares are issued pursuant to the exercise of an
Option, no fractional shares shall be issued and cash equal to the Fair Market
Value of such fractional share on the date of the delivery of the exercise
notice shall be given in lieu of such fractional shares.

     (c)  No shares shall be delivered pursuant to the exercise of any Option,
in whole or in part, until qualified for delivery under such securities laws 
and regulations as the Board of Directors may deem to be applicable thereto 
and until payment in full of the Option price is received by the Company in 
cash, by check or in shares of Common Stock as provided in Article 9 hereof.  
Neither the holder of an Option nor such holder's legal representative, 
legatee, or distributee shall be or be deemed to be a holder of any shares 
subject to such Option unless and until a certificate or certificates 
therefor is issued in his or her name or a person designated by him or her.

9.   Stock as Form of Exercise Payment.

     A Grantee who owns shares of Common Stock may elect to use the previously
acquired shares, valued at the Fair Market Value on the last Business Day
preceding the date of delivery of such shares, to pay all or part of the
exercise price of an Option, provided, however, that such form of payment 
shall not be permitted unless at least one hundred shares of such previously 
acquired shares are required and delivered for such purpose and the shares 
delivered have been held by the Grantee for at least six months.

10.  Withholding Taxes for Awards.

     Each Grantee exercising an Option as a condition to such exercise shall 
pay to the Company the amount, if any, required to be withheld from 
distributions resulting from such exercise under applicable Federal and State 
income tax laws ("Withholding Taxes"). Such Withholding Taxes shall be 
payable as of the date income from the award is includable in the Grantee's 
gross income for Federal income tax purposes (the "Tax Date"). The Grantee 
may satisfy this requirement by remitting to the Company in cash or by check 
the amount of such Withholding Taxes or a number of previously owned shares 
of Common Stock having an aggregate Fair Market Value as of the last Business 
Day preceding the Tax Date equal to the amount of such Withholding Taxes.

11.  Transfer of Awards.

    Options granted under the Plan may not be transferred except by will or 
the laws of descent and distribution or pursuant to a qualified domestic 
relations order, as defined in the Code, and, during the Grantee's lifetime, 
may be exercised only by said Grantee or by said Grantee's guardian or legal
representative, provided, however, that if Rule 16b-3 under the 1934 Act is
amended to permit restricted or unrestricted transfers of derivative 
securities granted under plans intended to qualify for the exemption 
provided by such rule, then if permitted in accordance with such 
transferability restrictions imposed by Rule 16b-3, if any, as so amended, 
the Options heretofore and hereafter granted under the Plan shall be 
transferrable without payment of consideration, to immediate family members 
of the Grantee or to trusts or partnerships for such immediate family 
members. 

12.  Death, Disability, Retirement and Termination of Director Status.

     (a)  An Option which has not theretofore expired shall terminate at the
time of the death of the Grantee or if the Grantee ceases to be a member of 
the Board, and no shares may thereafter be delivered pursuant to such 
Option, except that, subject to the condition that no Option may be 
exercised in whole or in part after the tenth anniversary of its Grant Date:

          (i)   Upon the termination of Board membership of any such Grantee 
                due to Disability or Retirement, the Grantee may, within a 
                period of three years after the date of such termination, 
                purchase some or all of the shares covered by the Grantee's 
                Options which were exercisable immediately prior to such 
                termination; and 
         (ii)   Upon the termination of Board membership of any such Grantee 
                due to any reason other than the Grantee's death, Disability 
                or Retirement, the Grantee may, within three months after 
                the date of such termination, purchase some or all of the 
                shares covered by the Grantee's Options which were exercisable 
                immediately prior to such termination,provided that, 
                notwithstanding the foregoing, the Options of a Grantee shall
                automatically terminate as of the date his or her 
                directorship is terminated, if terminated on account of any 
                act of(a) fraud or intentional misrepresentation, or (b) 
                embezzlement, misappropriation or conversion of assets or 
                opportunities of the Company or any Subsidiary; and 
        (iii)   Upon the death of any such Grantee while serving on the Board
                or of any such disabled or retired Grantee within the above-
                referenced period, the person or persons to whom the rights
                under the Option are transferred by will or the laws of 
                descent and distribution may, within twelve months after the 
                date of the Grantee's death, exercise some or all of the 
                Grantee's Options which were exercisable on the date of 
                death by the Grantee. 

13.  Change of Ownership.

   In the event of (a) a dissolution or liquidation of the Company, (b) a
merger or consolidation in which the Company is not the surviving corporation,
or (c) any other capital reorganization in which more than fifty percent (50%)
of the shares of the Company entitled to vote are exchanged, the Company shall
give to each Non-Employee Director, at the time of adoption of the plan for
liquidation, dissolution, merger, consolidation or reorganization, either (i)
a reasonable time thereafter within which to exercise the Option, prior to the
effectiveness of such liquidation, dissolution, merger, consolidation or
reorganization, at the end of which time the Option shall terminate, or (ii) 
the right to exercise the Option (or a substitute Option) as to an equivalent 
number of shares of stock of the corporation succeeding the Company or 
acquiring its business by reason of such liquidation, dissolution, merger, 
consolidation or reorganization.

14.  Adjustment Upon Changes in Capitalization.

     (a)  Changes in Capitalization.  If the number of shares of Common Stock
of the Company as a whole are increased, decreased or changed into, or 
exchanged for, a different number or kind of shares or securities of the 
Company, whether through merger, consolidation, reorganization, 
recapitalization, reclassification, stock dividend, stock split, combination 
of shares, exchange of shares, change in corporate structure or the like, 
an appropriate and proportionate adjustment shall be made in the number and 
kind of shares subject to this Plan, and in the number, kind, and per share 
exercise price of shares of Common Stock subject to unexercised Options or 
portions thereof granted prior to any such change.  Any such adjustment in 
an outstanding Option, however, shall be made without a change in the total 
price applicable to the unexercised portion of the Option but with a 
corresponding adjustment in the price for each share covered by the Option.  

    (b)  Acquisition.  Upon a reorganization, merger or consolidation in 
which the Company is not the surviving corporation, or upon the sale of all 
or substantially all of the property of the Company to another corporation,
provision shall be made in connection with such transaction for the assumption
of the Plan and the Options theretofore granted by the successor corporation. 
Provision may, alternatively, be made for the substitution for such Options of
new options of the successor corporation or a parent or subsidiary thereof.  
In any such case, appropriate adjustment as to the number and kind of shares 
and the per share exercise prices shall be made.  No fractional shares of 
stock shall be issued under the Plan on account of any adjustment specified 
above.

   (c)  Dissolution or Liquidation.  Upon the dissolution or liquidation of
the Company, this Plan and the Options issued thereunder shall terminate.

15.  Legal Restrictions.

     The Company will not be obligated to issue shares of Common Stock or 
make any payment if counsel to the Company determines that such issuance or 
payment would violate any law or regulation of any governmental authority or 
any agreement between the Company and any national securities exchange on 
which the Common Stock is listed.  In connection with any stock issuance or 
transfer, the person acquiring the shares shall, if requested by the Company, 
give  assurances satisfactory  to  counsel to the Company regarding such 
matters as the Company may deem desirable to assure compliance with all 
legal requirements.  The Company shall in no event be obliged to take any 
action in order to cause the exercise of any award under the Plan.

16.  No Rights as Shareholders.

     No Grantee, and no beneficiary or other person claiming through a 
Grantee, shall have any interest in any shares of Common Stock allocated for
the purposes of the Plan or subject to any award until such shares of Common
Stock shall have been transferred to the Grantee or such person.  
Furthermore, the existence of awards under the Plan shall not affect: the 
right or power of the Company or its stockholders to make  adjustments, 
recapitalizations, reorganizations or other changes in the Company's capital 
structure; the dissolution or liquidation of the Company, or the sale or 
transfer of any part of its assets or business; or any other corporate act,
 whether of a similar character or otherwise. 

17.  Board Membership.

     Nothing in the Plan or in any Option shall confer upon any Grantee any
right to continue as a director of the Company or interfere in any way with 
the right of the Company's shareholders to remove a director at any time.

18.  Choice of Law.

     The validity, interpretation and administration of the Plan
and of any rules, regulations, determinations or decisions made thereunder, 
and the rights of any and all persons having or claiming to have any interest
therein or thereunder, shall be determined exclusively in accordance with the
laws of the State of Connecticut.

19.  Amendment and Discontinuance.

     Subject to the limitation that the provisions of the Plan shall not be
amended more than once every six months other than to comport with changes in
the Code or regulations thereunder, the Board of Directors may alter, suspend,
or discontinue the Plan, but may not, without the approval of a majority of 
the holders of the Common Stock, make any alteration or amendment thereof 
which operates (a) to increase the total number of shares which may be 
granted annually under the Plan, (b) to extend the term of the Plan or the 
option periods provided in the Plan, (c) to decrease the option price 
provided in the Plan, or otherwise materially increase the benefits accruing 
to Grantees through awards under the Plan, or (d) to modify the eligibility
requirements for participation in the Plan. 


     Adopted by the Board of Directors at its meeting of September 13, 1994,
subject to approval of the Company's shareholders and the Connecticut 
Department of Public Utility Control.

Attest:



                                         
Secretary






                                                          APPENDIX A



                            STOCK OPTION AGREEMENT
                                  UNDER THE
                BIRMINGHAM UTILITIES, INC. STOCK OPTION PLAN
                         FOR NON-EMPLOYEE DIRECTORS



   Pursuant to Article 7 of the Birmingham Utilities, Inc. Stock Option Plan
for Non-Employee Directors (the "Plan"), Birmingham Utilities, Inc. (the
"Company"), this ____ day of _____________, 199__(the "Grant Date"), hereby
grants to ___________________________("Director") a non-qualified stock option
to purchase an aggregate of ____________ shares of the Common Stock of the
Company at $_____ per share, on the terms and conditions hereinafter set forth
and set forth in the Plan.  This option will expire at the Company's close of
business on ______________, 19__, unless sooner terminated in accordance with
the terms of the Plan.

     1.   The Company hereby grants to Director a non-qualified stock option
(the "Option") to purchase on or before the expiration date indicated above, 
at the purchase price stated above, the number of shares of the Company's 
Common Stock set forth above.  No option granted under the Plan shall be 
exercised or will vest unless and until the Plan is approved by the Company's
shareholders and the Connecticut Department of Public Utility Control.

     2.   The term of this Option shall commence on the date of this Agreement
and shall terminate, unless sooner terminated by the terms of the Plan, at the
close of business on the day preceding the tenth anniversary of the date of 
this Agreement as set forth above, if the Company is open for business on 
such day, or the close of the Company's business on the next preceding day 
that the Company is open for business.  Unless the Option is terminated or 
the time of its exercisability is accelerated in accordance with the Plan, 
the Option shall be exercisable only to the extent of one-half of the number
of shares of the Common Stock to which it relates on or after the first
anniversary of its Grant Date set forth above and shall be exercisable to 
the extent of the remaining one-half of such shares only on or after the 
second anniversary of the Grant Date, so that the Option shall be 
exercisable in full only on or after the second anniversary of the Grant 
Date.
This Option shall become immediately exercisable under the circumstances
described in Section 7(b)(iv) of the Plan.  

     3.   This Option may be exercised, in whole or in part, by written
notification delivered in person or by mail to the Secretary of the Company 
at its offices at 230 Beaver Street, Ansonia, Connecticut.  Such 
notification shall specify the number of shares with respect to which the 
Option is being exercised and shall be accompanied by payment for such 
shares.  The Secretary of the Company will provide Director with a form of 
exercise notice upon request.  The Option may not be exercised with respect 
to a fractional share.  Payment is to be made by check payable to the order 
of the Company or by one of the alternative methods of payment described in 
the Plan.  No shares shall be sold or delivered hereunder until full payment 
for such shares has been made and all checks delivered in payment therefor 
have been collected.  Director shall not have any rights of a shareholder 
with respect to any Common Stock received upon exercise of the Option until 
certificates for such Common Stock have been actually issued to Director 
in accordance with the terms hereof.

     4.   The Company shall not be required to issue or deliver any 
certificate or certificates for shares of its Common Stock purchased upon 
the exercise of any part of this Option prior to (i) the admission of such 
shares to listing on any stock exchange on which the stock may then be 
listed, (ii) the completion of any registration or other qualification of 
such shares under any applicable law, rule or regulation, (iii) the obtaining
of any consent or approval or other clearance from any governmental agency 
which the Company determines to be necessary or advisable, and (iv) the 
payment to the Company, upon its demand, of any amount requested by the 
Company for the purpose of satisfying its liability, if any, to withhold 
federal, state or local income or earnings tax or any other applicable tax 
or assessment (plus interest or penalties thereon, if any, caused by a 
delay in making such payment) incurred by reason of the exercise of this 
Option or the transfer of such shares thereupon.  The Option shall be 
exercised and shares of the Company's Common Stock issued only upon 
compliance with the Securities Act of 1933, as amended (the "Act"), and any
other applicable securities laws, and Director agrees  to comply with any
requirements imposed by the  Committee.  Because Director is an "affiliate"  
of the Company (as that term is defined in Rule 144 promulgated under the 
Act, and which generally includes directors), by accepting this Agreement, 
you agree that you will dispose of the stock acquired upon exercise of the 
Option only in compliance with Rule 144 or in such other manner as will not 
violate the Act and the rules and regulations promulgated thereunder, and 
any other applicable securities law.

     5.   This Option is not transferrable by Director otherwise than by will
or by the laws of descent and distribution or pursuant to a qualified 
domestic relations order, as defined in the Code, and is exercisable, during
Director's life, only by Director or by Director's guardian or legal 
representative, unless and to the extent transferability becomes permitted 
under the terms of the Plan.   Any attempted assignment, transfer, pledge, 
hypothecation or other disposition of the Option contrary to the provisions 
hereof shall be null and void.  This Option does not confer upon Director 
any right with respect to continuation of Director's service as a director 
of the Company or any of its subsidiaries, and will not interfere in any 
way with the right of the Company's shareholders or the shareholders of any 
of its Subsidiaries to terminate Director's service as a director.

     6.   Upon the termination of Director's service as a member of the Board
of Directors, the Director may exercise this Option, provided that it has
vested, to the full extent of the number of the shares of Common Stock 
remaining under such Option, regardless of whether such Option was 
previously exercisable, in accordance with the conditions of Article 12 of 
the Plan. 

     7.  This Option shall be irrevocable during the Option period and its
validity and construction shall be governed by the laws of the State of
Connecticut.  The terms and conditions herein set forth are subject in all
respects to the terms and conditions of the Plan, which shall be controlling. 
You agree to execute such other agreements, documents or assignments as may 
be necessary or desirable to effect the purposes of this Agreement.

     8.   The grant of this Option shall be binding and effective only if 
this Agreement is executed by or on behalf of the Company and by you and 
a signed copy is returned to the Company.

     9.   All capitalized terms used in this Agreement which are not defined
herein shall have the meaning given to them in the Plan unless the context
clearly requires otherwise.


                              BIRMINGHAM UTILITIES, INC.


                              By__________________________________
                                Its


- ----------------------------------------------------------------------------

     I hereby acknowledge receipt of the Stock Option (the "Option") granted
on the date shown above, which has been issued to me under the terms and 
conditions of Birmingham Utilities, Inc. Stock Option Plan for Non-Employee 
Directors.  I agree to conform to all of the terms and conditions of the 
Option and the Plan. 



Date: _______________           Your Signature: _________________________