Form 154 - Application For Certificate Of Withdrawal
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3Filing Fee: $50.00
ID Number: ____________
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Office of the Secretary of State
Corporations Division
100 North Main Street
Providence, Rhode Island 02903-1335
BUSINESS CORPORATION
____________
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
(To Be Filed In Duplicate Original)
Pursuant to the provisions of Section 7-1.1-112 of the General Laws, 1956, as amended, the undersigned corporation
hereby applies for a Certificate of Withdrawal from the state of Rhode Island, and for that purpose submits the following
statement:
1. The name of the corporation is
2. It is incorporated under the laws of
3. It is not transacting business in the state of Rhode Island.
4. It hereby surrenders its authority to transact business in the state of Rhode Island.
5. It revokes the authority of its registered agent in Rhode Island to accept service of process, and consents that service
of process in any action, suit or proceeding based upon any cause of action arising in Rhode Island during the time
the corporation was authorized to transact business in Rhode Island may thereafter be made on the corporation by
service thereof on the Secretary of State of the State of Rhode Island.
6. The post office address to which the Secretary of State may mail a copy of any process against the corporation that
may be served on him or her is:
7. The aggregate number of shares which it has authority to issue, itemized by classes, par value of shares, shares
without par value, and series, if any, within a class, as of the date of this application is:
Par Value or Statement that
Number of Shares
Class
Series
Shares are without Par Value
Form No. 154
Revised: 01/99
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