Exhibit 10.4


                           January 21, 2002                  Stock Option Grants

Mr. Fred C. Kuznik
39 Castleton Court
North Barrington, IL 60010

Dear Fred:

The Board of Directors Cable Design Technologies Corporation (the "Company")
(and Compensation Committee hereof) has granted to you ("Grantee"), nonqualified
stock options to purchase shares of common stock, par value $.01 per share (the
"Common Stock"), of the Company.  The grant date, option price per share, number
of option shares and plan under which each grant was made (each a "Plan") are as
follows:



                 -------------------------------------------------------------------------------
                                                               Number of
                                              Option Price       Option
                          Grant Date            per Share        Shares          Plan
                          ----------          ------------     ---------         ----
                 -------------------------------------------------------------------------------
                                                                   

                      December 21, 2001         $14.79         100,000         2001 Plan
                 -------------------------------------------------------------------------------

                      December 21, 2001         $14.79          59,820         LT Plan
                 -------------------------------------------------------------------------------

                      December 21, 2001         $14.79          40,180         Supplemental Plan
                 -------------------------------------------------------------------------------

                      December 28, 2001         $14.25         149,560         2001 Plan
                 -------------------------------------------------------------------------------

                      December 28, 2001         $14.25          50,440         Supplemental Plan
                 -------------------------------------------------------------------------------

                        January 4, 2002         $15.23         100,000         2001 Plan
                 -------------------------------------------------------------------------------


               "2001 Plan" = 2001 Long-Term Performance Incentive Plan; "LT
               Plan" = Long-Term Performance Incentive Plan; "Supplemental Plan"
               = Supplemental Long-Term Performance Incentive Plan


Each of the foregoing constitutes a separate option grant that was made on the
grant date specified above. This letter and attachment evidences each such
grant. Each option grant is subject to the terms and conditions of the Plan
under which such option grant was issued and those set forth in Schedule I
hereto, including vesting described in Schedule I, all of which terms and
conditions are incorporated herein. Please sign and return a copy of Schedule I
to confirm receipt and understanding of such terms.

Very truly yours,

CABLE DESIGN TECHNOLOGIES CORPORATION
at the direction of the Compensation Committee of the Board of Directors

By: _________________________________
     Charles B. Fromm
     Vice President, General Counsel

ATTACHMENT


Grantee: Fred C. Kuznik
Attachment to letter dated January 21, 2002
evidencing and describing option grants


                                  SCHEDULE I

                     CABLE DESIGN TECHNOLOGIES CORPORATION

                                   TERMS OF
                NONQUALIFIED STOCK OPTION AGREEMENT EVIDENCING
                    A GRANT OF A NONQUALIFIED STOCK OPTION

          Each of the option grants described in the letter referenced above and
to which these terms are attached (each a "grant," "option" or "option grant")
are subject to the following additional terms and conditions. All terms used but
not defined herein shall have the meanings given to them in the grant letter to
which this Schedule is attached, and if not defined therein, in the applicable
plan under which the grant was made. The grant and these terms constitute the
"Agreement" as used herein.

1.          Grantee Bound by Plan.  A copy of each applicable Plan has been
            ---------------------
     provided to Grantee, which Plans (as the applicable grant) is incorporated
     herein by reference and made a part hereof. Grantee hereby acknowledges
     receipt of a copy of each Plan and each Plan prospectus and agrees to be
     bound by all the terms and provisions thereof. Each Plan and any prospectus
     then in effect should be carefully examined before any decision is made to
     exercise the option.

2.          Exercise of Option. Subject to the earlier termination of the option
            ------------------
     as provided herein and in the Plan, each option grant may be exercised, by
     written notice to the Company in the form attached as Exhibit B hereto (or
                                                           ---------
     through such other procedure as is set up by the Company ), at any time and
     from time to time after the date of grant, but, except as otherwise
     provided below, such option shall not be exercisable for more than a
     percentage of the aggregate number of shares offered as set forth in the
     following schedule:


          Time Period in which                       Cumulative Percentage of
          Exercise Date occurs                    Shares from each Option Grant
          --------------------                                that
                                                        May Be Exercisable
                                                        ------------------


     Date of Grant through                                      20%
     December 10, 2002

     December 11, 2002 through                               up to 36%
     December 10, 2003

     December 11, 2003 through                               up to 52%
     December 2004

     December 11, 2004 through                               up to 68%
     December 10, 2005

     December 11, 2005 through                               up to 84%


     December 10, 2006

     December 11, 2006 and after                             up to 100%


provided that, subject to the other conditions of this Agreement, if prior to
- --------
the expiration of this option a Change of Control (defined in Exhibit A) occurs
                                                              ---------
then all of the then unvested options shall vest (i.e. the option shall be
 exercisable for all the shares).

An option shall not be exercisable in any event after the expiration of ten
years from the date of grant. An option may not be exercised for a fraction of a
share of Common Stock.

3.          Conditions to Exercise.  The option may not be exercised by Grantee
            ----------------------
     unless all of the following conditions are met:

     a.          Legal counsel for the Company must be satisfied at the time of
            exercise that the issuance of shares of Common Stock upon exercise
            will be in compliance with the Securities Act of 1933, as amended
            (the "Act") and other applicable United States federal, state, local
            and foreign laws;

     b.          Grantee must pay at the time of exercise the full purchase
            price for the shares of Common Stock being acquired hereunder, by
            paying in United States dollars by cash, tendering shares of Common
            Stock owned by Grantee which have a fair market value equal to the
            full purchase price for the shares of Common Stock being acquired,
            such fair market value to be determined in such reasonable manner as
            may be provided from time to time by the Committee or as may be
            required in order to comply with or conform to the requirements of
            any applicable or relevant laws or regulations, requesting that the
            Company withhold from the shares of Common Stock to be issued to the
            Grantee the number of shares necessary to satisfy the full purchase
            price, based on the fair market value of the shares of Common Stock
            determined as set forth in clause (ii); paying in such other form as
            the Committee may determine in its sole discretion, or tendering a
            combination of the forms of payment provided for above in clauses
            (i) through (iv) of this Subparagraph 3(b); provided, however, that
                                                        --------  -------
            any payment of the purchase price in the form of shares of Common
            Stock owned by the Grantee or to be issued to the Grantee shall be
            made in accordance with the Company's policy regarding transactions
            involving the Company's securities; and

     c.          Grantee must, at all times during the period beginning with the
            grant date of the option and ending on the date of such exercise,
            have been employed by the Company or one of its Subsidiaries,
            provided that if:

                 (i)  Grantee ceases to be so employed by reason of Grantee's
          disability or retirement (as such terms are defined in the Plan and
          interpreted and administered by the Committee) while holding the
          option which has not expired and has not been fully exercised Grantee
          may, at any time within three years of the date of the


          onset of such disability or retirement (but in no event after the
          expiration of ten years from the grant date), exercise the option with
          respect to the number of shares, determined under Paragraph 2 above,
          as to which Grantee could have exercised the option on the date of the
          onset of such disability or retirement (or with respect to such
          greater number of shares as determined by the Committee in its sole
          discretion) and any remaining portion of the option shall be canceled
          and no longer exercisable;

               (ii)   Grantee dies while holding the option which has not
          expired and has not been fully exercised, his executors,
          administrators, heirs or distributees, as the case may be, may, at any
          time within one year (or such other period determined by the
          Committee) after the date of death (but in no event after the Option
          has expired), exercise the option with respect to any shares,
          determined under Paragraph 2, as to which the decedent could have
          exercised the option at the time of his death (or with respect to such
          greater number of shares as determined by the Committee) and any
          remaining portion of the option shall be canceled and no longer
          exercisable; and

               (iii)  Grantee's employment with the Company or its Subsidiaries
          is terminated for any reason other than as provided in clauses (i) and
          (ii) above and on the date of such termination Grantee holds the
          option which has not expired and has not been fully exercised, Grantee
          may, at any time within 30 days after such date of termination (but in
          no event after the expiration of ten years from the grant date),
          exercise the option with respect to the number of shares, determined
          under Paragraph 2 above, as to which Grantee could have exercised the
          option on such date of termination (or with respect to such greater
          number of shares as determined by the Committee in its sole
          discretion), and any remaining portion of the option shall be canceled
          and no longer exercisable.

Any option that is not exercised within the periods contemplated in clauses (i),
(ii) and (iii) above shall be canceled and no longer exercisable.

4.        Transferability. The option may not be sold, assigned, transferred,
          ---------------
     pledged, hypothecated or otherwise disposed of by Grantee, except by will
     or the laws of descent and distribution and is exercisable during Grantee's
     lifetime only by Grantee. If Grantee or anyone claiming under or through
     Grantee attempts to violate this Paragraph 4, such attempted violation
     shall be null and void and without effect, and the Company's obligation to
     make any further payments (stock or cash) hereunder shall terminate. If at
     the time of Grantee's death the option has not been fully exercised,
     Grantee's estate or any person who acquires the right to exercise the
     option by bequest or inheritance or by reason of Grantee's death may, at
     any time within one year after the date of Grantee's death (but in no event
     after the expiration of ten years from the grant date), exercise the option
     with respect to the number of shares, determined under Paragraph 2 above,
     as to which Grantee could have exercised the option at the time of
     Grantee's death, or with respect to such greater number of shares as
     determined by the Committee in its sole discretion. The applicable
     requirements of Paragraph 3 above must be satisfied at the


     time of such exercise.

5.          Adjustments; Change of Control. In the event of any change in the
            ------------------------------
     number of shares of Common Stock outstanding by reason of any stock split,
     stock dividend, split-up, split-off, spin-off, recapitalization, merger or
     consolidation in which the Company is the surviving corporation, rights
     offering, reorganization, combination or exchange of shares, distribution
     to shareholders other than a normal cash dividend, or other extraordinary
     or unusual event occurring after the grant date specified above and prior
     to its exercise in full, the number of shares of Common Stock for which the
     option may then be exercised, the type of consideration for which the
     option may be exercised and the option price per share may or may not be
     adjusted so as to reflect such change, all as determined by the Committee
     in its sole discretion. In the event of a Change of Control, the Committee
     shall (i) if the Company is not the surviving corporation, provide for the
     conversion of this option into an option to acquire shares of the acquiror,
     with such adjustments to price and number of shares as the Committee deems
     to be equitable to reflect the conversion or (ii) if the Company is the
     surviving corporation, make such equitable adjustments to the price and
     number of shares to reflect such Change of Control. Notwithstanding
     anything in this Agreement to the contrary, the Committee may take the
     foregoing actions without the consent of the Grantee, and the Committee's
     determination shall be conclusive and binding on all persons for all
     purposes. Following any Change of Control in which the Company is not the
     surviving corporation, the term "Company" shall refer to the acquiror.

6.          Withholding of Tax.  It shall be a condition to the obligation of
            ------------------
     the Company to furnish shares of Common Stock upon exercise of an option
     (i) that Grantee (or any person acting under Paragraph 4 above) pay to the
     Company or its designee, upon its demand, in accordance with the Plan, such
     amount as may be demanded for the purpose of satisfying the Company's
     obligation to withhold federal, state, local or foreign income, employment
     or other taxes incurred by reason of the exercise of the option or the
     transfer of shares thereupon (the "Tax Withholding Amount"), and (ii) that
     Grantee (or any person acting under Paragraph 4 above) provide the Company
     with any forms, documents or other information reasonably required by the
     Company in connection with the grant. In order to satisfy the condition of
     clause (i), upon approval by the Committee, Grantee may (a) make payment of
     the Tax Withholding Amount in United States dollars cash, (b) tender shares
     of Common Stock owned by Grantee which have a fair market value equal to
     the Tax Withholding Amount, such fair market value to be determined in such
     reasonable manner as may be provided from time to time by the Committee or
     as may be required in order to comply with or conform to the requirements
     of any applicable or relevant laws or regulations, or (c) request that the
     Company withhold from the shares of Common Stock to be issued to the
     Grantee the number of shares which have a fair market value equal to the
     Tax Withholding Amount, based on the fair market value of the shares of
     Common Stock determined as set forth in clause (b), (d) make payment in
     such other form as the Committee may determine in its sole discretion, or
     (e) tender a combination of the forms of payment provided for above in
     clauses (a) through (d) of this Paragraph 6; provided, however, that any
                                                  -----------------
     payment in the form of shares of Common Stock owned by the Grantee or to be
     issued to the Grantee shall be made during the period beginning on


     the third business day following the date of release of the Company's
     quarterly or annual summary statements of sales and earnings and shall be
     made in accordance with the Company's policy regarding transactions
     involving the Company's securities. If the amount requested for the purpose
     of satisfying the withholding obligation is not paid, the Company may
     refuse to furnish shares of Common Stock upon exercise of the option.

7.          Financial Assistance.  In accordance with the provisions of the
            --------------------
     Plan, if Grantee meets all eligibility requirements on the date of the
     option exercise, as defined by the Committee, upon Grantee's request the
     Company may assist Grantee in obtaining financing from the Company or from
     a bank or other third party, in such amount as may be necessary to permit
     the exercise of the option and/or the payment of any taxes required to be
     withheld by the Company in respect thereof.

8.          Amendment or Substitution of Awards.  The terms of this Agreement
            -----------------------------------
     may be amended from time to time by the Committee in its sole discretion in
     any manner that it deems appropriate (including, but not limited to,
     acceleration of the vesting provisions of the option in Paragraph 2);
     provided, however, that no such amendment shall adversely affect in a
     material manner any right of Grantee under this Agreement without Grantee's
     written consent, unless the Committee determines in its sole discretion
     that there have occurred or are about to occur significant changes in
     Grantee's position, duties or responsibilities, or significant changes in
     economic, legislative, regulatory, tax, accounting or cost/benefit
     conditions which are determined by the Committee in its sole discretion to
     have or to be expected to have a substantial effect on the performance of
     the Company, or any Subsidiary, affiliates, division, or department
     thereof, on the Plan or on this grant under the Plan. The Committee may, in
     its sole discretion, permit Grantee to surrender this grant in order to
     exercise or realize the rights under other awards under the Plan, or in
     exchange for the grant of new awards under the Plan, or require Grantee to
     surrender this grant as a condition precedent to the grant of new awards
     under the Plan.

9.          Confidential Information.  Grantee acknowledges that in the course
            ------------------------
     of his employment, he will necessarily have access to become familiar with
     and, as an indispensable part of his employment, use trade secrets,
     customer lists and detailed customer-related information (some or all of
     which may constitute trade secrets), business plans, financial and other
     proprietary and confidential information (collectively "Confidential
     Information") concerning the Company and its Subsidiaries and that such
     knowledge and familiarity was and will continue to be of special, unique,
     and extraordinary value to the Company and its Subsidiaries. Grantee agrees
     that he will not reveal or disclose to any unauthorized person, or take and
     use for his own account any Confidential Information concerning the Company
     and its Subsidiaries unless and to the extent that (i) the information was
     or becomes available to Grantee on a nonconfidential basis from a source
     which is not bound by a confidentiality obligation to the Company or a
     Subsidiary or (ii) Grantee is required by a court of competent jurisdiction
     or otherwise compelled by law to disclose such Confidential Information. In
     the event that Grantee is so required or compelled to make such disclosure,
     such party shall cooperate with the Company to preserve in full the
     confidentiality of all Confidential Information whose disclosure is not
     required or compelled. Upon termination of employment, Grantee shall


     promptly return to the Company all materials and all copies of materials
     involving any Confidential Information in Grantee's possession or control.
     Grantee agrees to represent to the Company in writing that he has complied
     with the provisions of this paragraph 9(b) upon termination of employment.

10.         Administration.  Any action taken or decision made by the Company,
            --------------
     the Board, or the Committee or its delegates arising out of or in
     connection with the construction, administration, interpretation or effect
     of the Plan or this Agreement shall lie within its sole and absolute
     discretion, as the case may be, and shall be final, conclusive and binding
     on Grantee and all persons claiming under or through Grantee. By accepting
     this grant or other benefit under the Plan, Grantee and each person
     claiming under or through Grantee shall be conclusively deemed to have
     indicated acceptance and ratification of, and consent to, any action taken
     under the Plan by the Company, the Board or the Committee or its delegates.

11.         No Rights as Stockholder.  Unless and until a certificate or
            ------------------------
     certificates representing such shares of Common Stock shall have been
     issued to Grantee (or any person acting under Paragraph 4 above), Grantee
     shall not be or have any of the rights or privileges of a stockholder of
     the Company with respect to shares of Common Stock acquirable upon exercise
     of the option. No adjustment shall be made for dividends (ordinary or
     extraordinary, whether in cash, securities or other property) or
     distributions or other rights for which the record date is prior to the
     date such stock certificate is issued to Grantee.

12.         Investment Representation.  Grantee hereby acknowledges that the
            -------------------------
     shares of Common Stock which Grantee may acquire by exercising the option
     shall be acquired for investment without a view to distribution, within the
     meaning of the Act, and shall not be sold, transferred, assigned, pledged
     or hypothecated in the absence of an effective registration statement for
     the shares under the Act and applicable state securities laws or an
     applicable exemption from the registration requirements of the Act and any
     applicable state securities laws. Grantee also agrees that the shares of
     Common Stock which Grantee may acquire by exercising the option will not be
     sold or otherwise disposed of in any manner which would constitute a
     violation of any applicable securities laws, whether federal or state.

13.         Listing and Registration of Common Stock.  The Company, in its
            ----------------------------------------
     discretion, may postpone the issuance and/or delivery of shares of Common
     Stock upon any exercise of the option until completion of such stock
     exchange listing, or registration, or other qualification of such shares
     under any state and/or federal law, rule or regulation as the Company may
     consider appropriate.

14.         Rights of Participants.  Neither this Agreement nor the Plan creates
            ----------------------
     any employment rights in Grantee and the Company shall have no liability
     for terminating Grantee's employment. Grantee shall have no rights under
     the Plan other than as an unsecured general creditor of the Company except
     that insofar as Grantee may have become entitled to payment of additional
     compensation by performance of services,


     Grantee shall have the same rights as other employees under general law.

15.         Notices.  Any notice hereunder to the Company shall be addressed to:
            -------
     Cable Design Technologies Corporation, Foster Plaza 7, 661 Andersen Drive,
     Pittsburgh, Pennsylvania 15220, Attention: President, and any notice
     hereunder to Grantee shall be addressed to Grantee at Grantee's last
     address on the records of the Company, subject to the right of either party
     to designate at any time hereafter in writing some other address. Any
     notice shall be deemed to have been duly given when delivered personally or
     enclosed in a properly sealed envelope, addressed as set forth above, and
     deposited (with first class postage prepaid) in the United States mail.

16.         Counterparts.  This Agreement may be executed in one or several
            ------------
     counterparts, each of which shall constitute one and the same instrument.


17.         Binding Effect.  This Agreement shall be binding upon and inure to
            --------------
     the benefit of any successors to the Company and all persons lawfully
     claiming under Grantee.

18.         Severability.  Whenever possible, each provision of this Agreement
            ------------
     shall be interpreted in such manner as to be effective and valid under
     applicable law, but if any provision of this Agreement is held to be
     invalid, illegal or unenforceable in any respect under any applicable law
     or rule in any jurisdiction, such invalidity, illegality or
     unenforceability shall not affect any other provision or any other
     jurisdiction, but this Agreement shall be reformed, construed and enforced
     in such jurisdiction as if such invalid, illegal or unenforceable provision
     had never been contained herein. The parties agree that a court of
     competent jurisdiction making a determination of the invalidity or
     unenforceability of any term or provision of Paragraph 9 of this Agreement
     shall have the power to reduce the scope, duration or area of any such term
     or provision, to delete specific words or phrases or to replace any invalid
     or unenforceable term or provision of Paragraph 9 with a term or provision
     that is valid and enforceable and that comes closest to expressing the
     intention of the invalid or unenforceable term or provision, and this
     Agreement shall be enforceable as so modified.

19.         Remedies.  The parties hereto agree and acknowledge that Grantee's
            --------
     breach of Paragraph 9 of this Agreement shall materially and irreparably
     harm the Company and its Subsidiaries, that money damages shall accordingly
     not be an adequate remedy for any breach of the provisions of Paragraph 9
     of this Agreement by Grantee and that the Company in its sole discretion
     and in addition to any other remedies it may have at law or in equity may
     apply to any court of law or equity of competent jurisdiction (without
     posting any bond or deposit) for specific performance and/or other
     injunctive relief in order to enforce or prevent any violations of the
     provisions of this Agreement.

20.         Delivery by Facsimile.  This Agreement, and any amendments hereto or
            ---------------------
     thereto, to the extent signed and delivered by means of a facsimile
     machine, shall be treated in all manner and respects as an original
     agreement or instrument and shall be considered to have the same binding
     legal effect as if it were the original signed version thereof delivered in
     person. At the request of any party hereto or to any such agreement, each


     other party hereto or thereto shall re-execute original forms thereof and
     deliver them to all other parties. No party hereto or to any such agreement
     shall raise the use of a facsimile machine to deliver a signature or the
     fact that any signature or agreement was transmitted or communicated
     through the use of a facsimile machine as a defense to the formation of a
     contract and each such party forever waives any such defense.

21.         Governing Law.  The validity, construction, interpretation,
            -------------
     administration and effect of the Plan, and of its rules and regulations,
     and rights relating to the Plan and to this Agreement, shall be governed by
     the substantive laws, but not the choice of law rules, of the State of
     Delaware.

                             *   *   *   *   *   *

            The Grantee has reviewed the foregoing and acknowledges that the
option grant to which this Schedule I is attached is subject hereto. The Grantee
agrees to be bound by the terms of this Schedule I.


Dated:  _______________


Fred C. Kuznik


                                                                       EXHIBIT A

                                  Definitions
                                  -----------

"Change in Control" shall be deemed to have occurred if:
 -----------------

          (a)  any "person" or "group" (as such terms are used in Section 13(d)
     of the Securities Exchange Act of 1934, as amended (the "Exchange Act")) is
     or becomes the "beneficial owner" (as defined in Rule 13d-3 under the
     Exchange Act), directly or indirectly, of securities of the Company
     representing 50% or more of the combined voting power of the Company's then
     outstanding securities; or

          (b)  there shall be consummated any consolidation, merger,
     reorganization or acquisition involving the Company unless following such
     event (i) all or substantially all of the individuals and entities who were
     the beneficial owners of the outstanding voting securities of the Company
     immediately prior to such event beneficially own, directly or indirectly,
     more than 55% of the combined voting power of the then-outstanding voting
     securities entitled to vote generally in the election of directors of the
     corporation resulting from such event in substantially the same proportions
     as their ownership immediately prior to such event and (ii) the provisions
     of clause (a) above are not met and (iii) at least 55% of the members of
     the board of directors of the corporation resulting from such event were
     members of the board of directors at the time of the initial consideration
     of, or any action of the board relating to, such event; or

          (c)  any sale, lease, exchange or other transfer (in one transaction
     or a series of related transactions) of all, or substantially all, of the
     assets of the Company (on a consolidated basis); or

          (d)  the stockholders of the Company approve any plan or proposal for
     the liquidation or dissolution of the Company; or

          (e)  as the result of, or in connection with, any cash tender offer,
     exchange offer, merger or other business combination, sale of assets, proxy
     or consent solicitation, contested election or substantial stock
     accumulation (a "Control Transaction"), the members of the Board
                      -------------------
     immediately prior to the date the Company initiates, or is notified of,
     such Control Transaction (the "Incumbent Board") shall thereafter cease to
                                    ---------------
     constitute at least a majority of the Board; provided, however, that for
     purposes of this clause (e) any individual becoming a director subsequent
     to the date hereof whose election, or nomination for election by the
     Company's shareholders, was approved by a vote of at least a majority of
     the directors then comprising the Incumbent Board shall be considered as
     though such individual were a member of the Incumbent Board, but excluding,
     for this purpose, any such individual whose initial assumption of office
     occurs as a result of an actual or threatened election contest with respect
     to the election or removal of directors or other actual or threatened
     solicitation of proxies or consents by or on behalf of a person other than
     the Board.


"Subsidiary" shall mean any corporation of which the securities having a
 ----------
majority of the voting power in electing directors are, at the time of
determination, owned by the Company, directly or through one or more
Subsidiaries.


                                   EXHIBIT B
                                   ---------


                         Form of Letter to be Used on
                           Exercise of Stock Options

                                                                 _______________
                                                                            Date

Cable Design Technologies Corporation
Foster Plaza 7
661 Andersen Drive
Pittsburgh, Pennsylvania 15220
Attention:  President

Dear Sir:

          I wish to exercise the stock option granted on ____________, ____ and
evidenced by my Supplemental Long-Term Performance Incentive Plan Stock Option
Agreement dated ____________, ____ to the extent of ________ shares of the
Common Stock of Cable Design Technologies Corporation, at the option price of
$________ per share. My check in the amount of $________ in payment of the
entire purchase price for these shares accompanies this letter.

          Please issue a certificate for these shares in the following name:

          ___________________________________
          Name

          ___________________________________
          Street Address

          ___________________________________
          City/State/Zip

                                        Very truly yours,


                                        _______________________
                                        Signature

                                        _______________________
                                        Typed or Printed Name

                                        ________________________
                                        Social Security Number