Fillable Form C025.001 - Application For Withdrawal

Form C025.001 - Application For Withdrawal - 2010 Page 2

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8. REQUIRED – list the mailing address to which the Arizona Corporation Commission may mail

a copy of any documents or process served on the Commission pursuant to its appointment as

the foreign corporation’s agent for service of process:

Attention (optional)

Address 1

Address 2 (optional)

State or

City

Zip

Province

Country

By the signature appearing below, the foreign corporation (for-profit or nonprofit) hereby agrees

to notify the Arizona Corporation Commission in the future of any change in the foreign

corporation’s mailing address.

NUMBERS 10 through 12 APPLY ONLY TO CORPORATIONS THAT CHECKED

NUMBER 4.2 ABOVE.

10. The foreign corporation (for-profit or nonprofit) certifies under penalty of perjury by the

signature appearing below that no debt of the foreign corporation acquired in Arizona remains

unpaid.

11. The FOR-PROFIT foreign corporation certifies under penalty of perjury by the signature

appearing below that a majority of its duly authorized officers authorized the withdrawal.

12. The NONPROFIT foreign corporation certifies under penalty of perjury by the signature

appearing below that a majority of its directors or members authorized the withdrawal.

SIGNATURE:

By checking the box marked "I accept" below, I acknowledge under penalty of

perjury that this document together with any attachments is submitted in

compliance with Arizona law.

I ACCEPT

Signature

Printed Name

Date

REQUIRED – check only one:

I am the Chairman of the Board

I am a duly-authorized Officer of

I am a duly authorized

of Directors of the corporation

the corporation filing this document.

bankruptcy trustee, receiver,

filing this document.

or other court-appointed

fiduciary for the corporation filing

this document.

Filing Fee: $25.00 (regular processing)

Mail:

Arizona Corporation Commission - Corporate Filings Section

Expedited processing – add $35.00 to filing fee.

1300 W. Washington St., Phoenix, Arizona 85007

All fees are nonrefundable - see Instructions.

Fax:

602-542-4100

Please be advised that A.C.C. forms reflect only the minimum provisions required by statute. You should seek private legal counsel for those matters that may pertain

to the individual needs of your business.

All documents filed with the Arizona Corporation Commission are public record and are open for public inspection.

If you have questions after reading the Instructions, please call 602-542-3026 or (within Arizona only) 800-345-5819.

C025.001

Arizona Corporation Commission – Corporations Division

Rev: 2010

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